I know we all have visions of our ideal nursing scenario for every mother.  One thing we still have
to contend with is the cultural & familial settings of the women with whom we work.  This means
that there are sometimes tremendous gaps between our vision and mom's situation.

I still struggle with this on a day to day basis because I live in a country that has made marvelous
technological advances in medicine and at the same time has a very poor track record on public
health.  I worked for over 20 years in developing country settings and I know what is lost in terms
of lack of tertiary care in those settings - the high infant, child, and maternal mortality rates.  Yet,
I am still astounded at how far away the Manhattan hospitals are from creating a breastfeeding
friendly environment.  Not one meets the Baby Friendly Hospital Initiative Standards yet.  Having
worked in fun places like Niger, Cambodia, Bangladesh, I still can't quite fathom why we can have
women who are going for 7 rounds of IVF and save 1 pound babies, yet we can't manage to create
a single hospital that meets the BFHI standards.  Nevertheless, I've accepted that it is a system that
I have to work around.  I almost NEVER see a baby that hasn't had formula.  Often parents will say
the baby had no formula and then it will come out during the consultation that there was just that
one little bottle before the milk came in (that doesn't really seem to count in the parents' minds).

I also work in a culture that is foreign to me.  I didn't realize how much I had absorbed in terms of
child care practices during my early to middle adulthood from observing all the different cultures I
worked in.  When my son was in nursery school, I felt as if I were on an archeological expedition
sitting in Starbucks listening to Prada bag conversations thinking that I would be more at home
under an acacia tree on a mat under the hot sun in Niger with a group of women talking about the
value of drying mangos.  So, I try to think of myself as living in a foreign culture (which is sort of
true for me even though I grew up in the US) that I don't quite understand and have to really
explore the cultural practices to understand how to make incremental changes.

One of my hard learned lessons from my previous public health days is that you cannot expect
change to happen overnight AND that you cannot always change things by focusing on the woman
alone.  You have to have patience and try to look at the support systems, not just the mom.

Richard Manoff (who was instrumental in starting social marketing for international health
purposes) always had a big thing about how we had gone overboard placing all the burden on
mom.  He would list off all the things that mom was supposed to do --- boil the water, collect the
water, drag her children into the local health center (which might be up to 20 miles away) for
monthly weight checks, for immunizations, for oral rehydration salts in the event of diarrhea, for
iron supplements during her pregnancy, collect the firewood to make the 3-4 fresh meals a day
for the children older than three months, use active feeding when the children were sick, etc.  Its
been a while, so I can't even remember the whole list of things moms were supposed to do in
these developing country settings.   Then he'd talk about the support systems that really needed
to be built up around her so that she was not the one taking on the entire burden and getting all
the blame.  I saw how successful some of his ideas could be when translated into action.  For
instance, in Niger - they did messages for men who really controlled the money there.  "Buy your
wife 20 cfa (the local currency) worth of liver snacks once a week during her pregnancy."  I can't
remember the motivation, but I bet it was something about how she wouldn't be so tired (with the
thought that the men would see a less exhausted wife as an advantage).  These messages targeted
at other family members really worked.

I know that we often see women as our clients and some of us may not have much connection
with public health programs, but there are ways that we can work on these issues.  One
subsegment of the population I see, routinely uses baby nurses.  Believe it or not, I've started
recruiting baby nurses on my side.  Some of them are tough nuts to crack, but some can be
trained.  I focus on praising them for the good things that they do (whatever I can observe) and try
to keep in mind that the baby nurse is the one that is up with the baby all night long for a
relatively low paying job where she has to sleep in some small closet in a strangers home.  If I can
recruit her on my side - I have someone there who can follow through on the advice at most
feedings of the day.

I get discouraged by pediatricians at times, but I still keep right on writing my reports again and
again and again.  I had a recent success with a mom who only came to support group.  Her
pediatrician who is pretty hopeless with breastfeeding advice, is now actually asking this mother
how she's managed to get her slow-gaining baby to turn around and start gaining and feeding
vigorously from the breast.  So mom passes along the advice she's gleaned from support group.
So every week this pediatrician gets a dose of how things can be turned around.

So, even if you get discouraged by the one mom that is bowing down to all the negative pressures,
remember that you alone may not be enough for this particular mom, but over the course of your
work you will have a positive influence on many women AND many others who also support these
women.  Drag out your files and look at the successful cases - and think about those health care
practitioners who might have shifted their practices because of your steady perseverence.

As for the breastfeeding tents - yes, they are pretty unattractive for those of us who know what
unfettered nursing is like.   But there are gradual ways of helping mothers feel more comfortable.
One of the first steps is to acknowledge the mother's discomfort.  Her discomfort did not appear
overnight.  Mom developed those uncomfortable feelings about exposing her breasts after a
lifetime of cultural and familial messages.  She is not going to drop them immediately, just
because we tell her or show her it is OK to do.  Acknowledging that it brings up uncomfortable
feelings, acknowledging that it make take a while to feel more comfortable can help her process
those feeling.  I ALWAYS keep in mind that it took me a full 10 years after living in what was then
Zaire, to be able to wear a pair of shorts. In that culture - thighs and the buttocks are the sexual
symbols.  After 2 years in Zaire, it felt every bit as uncomfortable for me to wear shorts as it would
feel for most American women to strut down mainstreet topless.  And I felt that way after only 2
years exposure to Zairian culture.   I usually find if I acknowledge the "Ew yuck" response, whether
it is nursing in public or mentioning that body fluid ---- gasp ---- human donor milk, or talking
about child-led weaning in prenatal breastfeeding classes, then mom is generally more receptive
to listening about how to diminish or cope with the "Ew yuck" response.

 Best regards, Susan Burger, MHS, PhD, IBCLC

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