Cindy mentioned on 18 Feb her surprise that Ziemer's literature
review revealed no research studies which show that positioning and
attachment prevent or even reduce the incidence of painful
breastfeeding.  This may be correct but it is not to say that p&a
are no use, just that the studies have not been done.

I have had the opportunity to observe (only briefly, alas) cultures
where breastfeeding is more "natural", and I agree with Katherine
Dettwyler that they don't have the problems we take for granted. My
observation is that good p&a is only one of many factors that
determine whether or not mothers have breastfeeding problems.

However, until we can recreate a "perfect breastfeeding world" in
our local area, some mothers will get (iatrogenic) breastfeeding
problems.  We still need the clinical skills to help them, which is
what Mary Ziemer's article was all about.  LCs may earn a living
downstream from poor practices, but my guess is that we are not
likely to become redundant in the near future.

I understand that one recent study (unfortunately it is still under
pre-publication wraps so I can't quote it) found that really good
antenatal education (including excellent p&a) did not *prevent*
problems such as sore nipples from occuring at the same rate as in
the control group.  It only made the mothers much more likely to
perservere through the problems and breastfeed for much longer than
the control group.  I think there have been other studies on
antenatal education that confirmed this.

My vote (its double election time here) is for people who are
prepared to stick their necks out and at least do the research, and
for more people to take classes in evaluating research. As a group,
IBLCE exam candidates consistently perform poorly on the research
questions!

Ros Escott
Hobart, Tasmania (where summer has finally arrived)
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