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