Dear all:

One of the difficulties that we all have to accept when we deal with women one on one is that we 
are not the only person that a mother listens to when making decisions about her baby.  I'm sure 
that there is no one on this list who hasn't experienced the same frustration that Amy 
experienced.  I appreciate her sharing because I don't feel so alone when I want to tear my hair out 
over some advice that some mother followed.  This week it was the pediatrician who suggested IN 
WRITING on a prescription pad to give water to stave off feeding for three hours and one relief 
bottle per day of formula for a mother whose baby was 14% below birth weight at two weeks of 
age.  The prescription contained no information about pummping.

In our roles as lactation consultants we have less influence the larger population of "influencers' 
surrounding the mother.  Those of us running public health or educational programs may have an 
opportunity to influence these others.  I think I mentioned this about Niger already, but some of 
the nutritional programs got stuck with traditional education approaches.  The standard 
international nutrition group counseling at the clinic showing moms how to prepare a safe and 
nutrious complementary weaning gruel when your baby was six months old really didn't do it.  
What worked was a radically different approach with social marketing influences some of the 
"influencers" of mothers.  In Niger, they actually started to get the Dads to buy liver snacks for 
their mostly very anemic pregnant wives.  The messages were not targeted to moms at all.  The 
parenting center where we do our breastfeeding support groups and prenatal classes has a very 
nice handout explaining to grandmothers who haven't breastfed why and how they can support 
their daughters.  

For those of us who don't have as much influence over the larger educational/public health 
environment, I suggest taking the  three-step counseling method a bit further once you get 
comfortable with "validating" the mothers feelings.  Every single social marketing or counseling 
model includes that step in there.  You can't really get to far without it.  BUT.. even that may not 
be enough.  

One type of social marketing has branched off into what is known as "Trials of Improved 
Practices".  The ultimate goal of this is to do the qualitative research to implement a larger public 
health program.  I think that it is perfectly good for use in a setting where you are doing clinical 
work as well and can inform how you move forward with those difficult cases which we all see over 
and over in infinite slight variations on a theme.

I have to confess that I found it really uncomfortable at first because you may not necessarily go 
for the "Best" practice.  You give the mother an array of choices for a particular behavior.  Some of 
the choices may be better than moms current practices, but may not necessarily achieve the 
biological "Ideal".  (This is the part that I had trouble with at first).  Then you work with mom to 
help her implement her choice.  In a research setting this would be when the researchers would be 
figuring out how to create a counseling, radio or other media message to convince a larger 
population of similar mothers, dads, grandmothers, etc.  Information would be collected about 
how mom reacted to this change, the barriers for her and what helped her finally adopt the 
change.

When I think about good lactation consultants -- I find that they tend to do "Trials of Improved 
Practices" naturally.  You look at the totality of mom's situation.  You give moms the information 
and a few choices that mom can comprehend --- without trying to fix everything that you know 
should be fixed. You set up a defined period (a few days, a week, etc) during which mom will try to 
implement these changes.  You work with mom to implement the choices that she can make.  
Sometimes during the implementation, mom will realize that she can actually do more than she 
thought she could and you can push her to get closer to the ideal.  You store up your own 
experience with this type of problem (or cultural belief about infant feeding) and remember what 
worked and what didn't for the next time around.

The approach I adopt with some of the Upper East Side moms with a baby nurse who want to do a 
little nursing are not the same as the approach I would use with a downtown mom who plans on 
carrying her baby around in a sling for the next three years.  Depending on the mom, I'm going to 
make more progress with the mom who is set on the baby nurse by getting her to pump when she 
wakes up to go to the bathrooom at night and really focus on helping her breastfeed during teh 
day than insisting she get up and feed the baby.   Do I think that is the ideal?  NO.  Can I 
sometimes get that type of mom to nurse through the night? YES.  But when I can't, I can at least 
preserve or increasea the milk supply and start getting mom to enjoy the breastfeeding during the 
day so she might do it longer than a token three months.

Best, Susan.

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