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advocacy and commentary with a focus on Lane County, Oregon

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Stepping Toward A Baby-Friendlier Oregon

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The Breastfeeding Coalition of Oregon under the direction of Amelia Psmythe recently hosted its sold-out 5th annual two-day statewide conference – Stepping Toward A Baby-Friendlier Oregon. Supporters who made the conference possible include Oregon WIC, Oregon Public Health Institute, Hygeia, Limerick, and Medical International.

Anyone wanting to know what Oregon’s many infant-feeding stakeholder groups are up to should make a habit of attending. While there is still so much to be done to protect and promote breastfeeding, the following downloadable synopsis of conference presentations will give you a quick bird’s eye view of the excellent and diverse work already underway.

Oregon is fortunate to have an extraordinarily talented cadre of savvy, skilled and committed advocates for quality care. Throughout the state, these advocates promote and protect women’s health, well being and basic human rights spanning the entire arc of their reproductive lives whether at home, in the community, in the health care system, in the economy or as “subjects” of scientific research and inquiry. The BCO annual conference is a good opportunity to check in and rally for the difficult but critical work ahead to achieve breastfeeding’s full-spectrum benefits for the entire population.

Framing the discussion…Presentations and discussion were conceived of and organized to align with the Surgeon General’s Call to Action to Support Breastfeeding (SGCTA). The SGCTA is a federal tool to direct policy, fund activities and align stakeholders around important objectives outlined in Healthy People 2020. Federal, state and local grants and staffing resources are made available and prioritized based on alignment with SGCTA objectives.

The SGCTA to Support Breastfeeding is a ground-breaking document because it is a clear departure  from previous policy and political frameworks that define breastfeeding as an individual responsibility or lifestyle choice beyond the concern, responsibility and reach of government focus. Finally, breastfeeding behaviors and outcomes have been re-defined as the product of cultural norms and structures at all levels of society. Accordingly, public health workers, researchers, employers, health care systems, communities and families are “called to action” to better and more effectively support mothers and babies to breastfeed.

Presentation Synopses. Following is a list of presentations. It gives a wide-angle view of how individuals and institutions are aligning Oregon with the SGCTA. Click here for a version of this post that also includes a synopsis of each presentation.

The Role of Consumer Advocacy in Increasing E-B Infant Feeding Practices
Katharine Gallagher, MPP. Consumer advocate, blogger and independent childbirth educator.
slides
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Let’s Talk! Breastfeeding Education Series Tear Sheet Project
Rachel Martinez, BA, IBCLC, RLC. New Member Training Coordinator at Nursing Mothers Counsel of Oregon, and Legacy Emmanuel Hospital lactation consultant.

The Oregon Black Women’s Birth Survey
Shafia Monroe, Midwife. Founder of the International Center for Traditional Childbearing

Supporting Families the Whole Way: Continuity Care Model
Debbie Alba, RN, IBCLC. Nurse and Lactation Consultant at Good Samaritan Regional Medical Center, currently serving as Western Region Steering Committee Chair

Angie Chisholm, CNM. Certified Nurse Midwife at Samaritan OB/GYN in Corvallis, with a long interest in lactation and evidence-based care.

Oregon WIC Peer Counseling: A Public Health Approach
Kelly Sibley, MPH, RD, IBCLC. Nutrition Consultant and Breastfeeding Coordinator with the Oregon State WIC Program. Coordinates WIC BF peer counselors.

Engaging Community Partners in Breastfeeding Support
Helen Bellanca, MD, MPH. Family physician who has worked with health policy and advocacy for four years, leading insurance collaborative and child care survey.

Lessons Learned on the Way to Baby-Friendly: Providence Newberg
Joanne Ransom, RN, IBCLC. Labor & delivery nurse and lactation consultant at Providence Newberg, former Vice-Chair of Northwest Mothers Milk Bank, new OEBIN co-lead

Redesignation with Baby-Friendly: Strategies for Success
Michelle Stevenson, RN. Perinatal Nurse and former La Leche League Leader, led two CA hospitals to Baby-Friendly designation, and now manages the Women and Newborn Care and Nursery at Kaiser Sunnyside Hospital.

Eliminating Elective Deliveries Prior to 39 Weeks Gestation: OR Challenge
Joanne Rogovoy, Executive Director of the Oregon March of Dimes, and leader of the workgroup that banned early c-sections on Portland area hospitals.

Donor human milk & Northwest Mothers Milk Bank
June Winfield, Board Chair / Director

Breaks for Nursing Mothers are Federally “Reasonable”
Amelia Psmythe, Director of the Breastfeeding Coalition of Oregon and West Region Coalition Representative to the United States Breastfeeding Committee.

Nursing Mothers Counsel Workplace Lactation Support Program
Marion Rice, Ed.D. 25 year educator, currently leads the Nursing Mothers Counsel of Oregon Worksite Lactation Support Program

What Do Women Really Want? A 21st Century Mother’s Movement
Andrea Paluso, MSW, MPH. Co-founder of Family Forward Oregon, The Mother PAC, and recent graduate of the Emerge Oregon legislative mentoring program.

Breastfeeding Outcomes in Women with a Prior History of Cesarean Section
Cathy Emeis, PhD, CNM. A nurse-midwife and researcher at OHSU, Cathy’s current research examines the impact of birth interventions and c-section on breastfeeding.

Breastfeeding Coalition of Oregon: Northwest Edge of the Wave of Change
Amelia Psmythe, Director of the Breastfeeding Coalition of Oregon and West Region Coalition Representative to the United States Breastfeeding Committee

US Breastfeeding Committee Annual Report
Robin Stanton, MA, RD, LD. USBC Past-Chair and Nutrition Consultant with OR Department of Human Services, Public Health Division

Collaboration for Collective Impact
Amelia Psmythe and Robin Stanton, MA, RD, LD

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Part 2: Consumer Advocacy & Evidence-Based Infant Feeding Practices

Here’s the second “installment” for my upcoming presentation at the March 2-3 Breastfeeding Coalition of Oregon’s 5h Annual Meeting. Blue text indicates information that will be placed on PowerPoint slides, black text indicates what will be said. I’d love your feedback either here or via email at motherbabynetwork@gmail.com. Read the first installment

This installment covers consumer demand, consensus spanning breastfeeding research, accountability organizations and national and state governments, and the new Joint Commission “Speak Up!”campaign.

What does consumer demand by the numbers look like?

Click on chart to enlarge

These statistics, taken from the CDC 2011 Breastfeeding Report beautifully illustrate the strong consumer demand on the part of women to breastfeed. Oregon has exceeded the Healthy People 2020 goal for 81.9% initiation of breastfeeding. What this tells us is that most women today plan to breastfeed – more than 91% initiate breastfeeding. This is great news. But within six months we see a dramatic drop-off, especially when we consider breastfeeding exclusivity. Why is this?

Behind these declining rates are the potholes and gaps of an inadequate infrastructure entirely incapable of meeting and supporting women and families in their infant feeding decision to breastfeed. Soon after or right along with the first latch, mothers and babies face multiple threats to breastfeeding from several angles that hound, hobble and thwart them all along the way. Behind these numbers lurk the stories of women and families who are forced into a choice they initially rejected – formula feeding. Who among us doesn’t know first or second hand the details of these unanticipated transitions to formula and the associated loss of maternal and child health benefits?

What these numbers also fail to illustrate are the social and ethnic inequities perpetuated via barriers to breastfeeding. Unacceptable disparities in breastfeeding persist by race/ethnicity, socioeconomic characteristics, and geography. Here in Oregon, only 25% of African-American mothers and babies are breastfeeding at six months, compared to the 62% of Oregonians. (ICTC Black Birth Survey)

Important as data collection is, standard metrics do not capture the emotions, frustrations and isolation women and families experience when faced with the unanticipated and multiple barriers that threaten and frequently succeed in separating babies and mothers from breastfeeding.

In sum, our maternity care system falls woefully short of meeting consumer demand for effective breastfeeding services. Fortunately, consumers (mothers) are beginning to connect the contradictory advice they receive from physicians, nurses, lactation consultants, nurses’ aids and housekeeping staff with the poor outcomes they experience. More women are beginning to see how gaps in standard hospital practice undermine them before they ever go home to struggle alone. The actions and activities of innumerable local and national groups sprouting up are giving voice to the dissatisfaction women and families feel with the standard of care.

Consumers are not alone in connecting the dots…..

Click on chart to enlarge

In the big picture, women are no longer alone in their search for meaningful support. The time for big change in maternity care is here.

Research

  • Health benefits. We are beyond debating the pros and cons of biologically normative infant feeding. Multiple short- and long-term health benefits of breastfeeding for mothers and babies have been firmly established.
  • Hospital practice. Research conclusively demonstrates that evidence-based hospital practices positively influence breastfeeding duration and exclusivity.
  • Cost savings. Thanks to Bartick et al’s 2009 cost analysis (The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis), we also have clear documentation of the massive projected savings in dollars and lives that come with exclusive breastfeeding.
  • SIDS. 2011 research confirms breastfeeding is associated with reduced rates of SIDS. The effect is stronger when breastfeeding is exclusive. This finding has special significance for my community of Lane County. Between July 2007 and June 2010, 23.5% of 85 fetal-infant mortalities are among post-neonates (babies one month or older). Breastfeeding reduces the risk of SIDS.
  • Childhood obesity. Breastfeeding is associated with reduced odds of obesity throughout the life span with greater benefits conferred with exclusive breastfeeding. Breastfeeding promotion and childhood obesity risk reduction go together.

Accountability

Consumer voices and research findings are increasingly making their way to the top of the agenda for major actors in the development and implementation of health care policies. As these bodies move beyond signaling interest to taking action, forward-thinking hospitals will take action to be in position for a time when reimbursement dollars will be tied to breastfeeding outcomes. Action means adopting evidence-based practice for infant feeding.

  • CDC mPINC. A national survey of hospitals to measure infant feeding policies and practices. Facilities receive private analyses outlining their strengths and areas that need improvement. Unfortunately, consumers are not permitted access to facility-level reports.
  • Joint Commission. The nation’s most important hospital-accrediting body recently included exclusive breast milk feeding in its new perinatal core measure set.
  • US Surgeon General Call to Action and Healthy People 2020. Both documents guide national, state and local health policy making. Increasing the number of breastfed infants is a key public health goal.

Nation

  • Healthcare reform. is a major national issue. Promoting and protecting the rights of nursing mothers to pump included in legislation.
  • Let’s Move. The First Lady’s campaign includes breastfeeding as part of the solution to the childhood obesity epidemic.
  • Transforming Maternity Care. Maternity and infant care are the most expensive hospital condition in the United States – $98 billion in 2008. The US spends more than any other industrialized country on maternity and infant care. The outcomes do not support this spending. Any discussion of improving the healthcare delivery service must focus on maternity and infant care.
  • Breastfeeding. Discussion of infant feeding reform thus fits within a larger context spanning the entire perinatal period from conception through an infant’s first birthday.

Oregon

  • WIC. Oregon WIC is one of only 6 states awarded a Breastfeeding Performance Bonus from USDA, tied for the first time to exclusive breastfeeding rates.
  • Oregon Hospitals Partnering for Evidence-based Infant Nutrition. This is a statewide project of the BCO to provide facility-specific technical assistance and encouragement to hospitals adopting evidence-based practices. The May 2011 hospital summit brought hospitals and community groups together to develop plans for next steps. This summit provided my community’s two leading hospitals (McKenzie Willamette Medical Center and Sacred Heart Medical Center) with an opportunity to publicly share their commitment to become Baby Friendly-designated facilities.
  • Oregon Health Insurers Partnering for Prevention (OHIPP). This group of health insurers selected breastfeeding as an evidence-based prevention strategy for reducing obesity. Incentives to hospitals that attain the Baby-Friendly designation are being explored.

The Joint Commission’s message to mothers? Speak Up!

Now that consumers are joined by research scientists and health policy makers at the national and state levels, we are beginning to see efforts to encourage women to seek and insist on excellent infant feeding care. Having recently signaled to US hospitals that exclusive breast milk for infant nutrition is increasingly on the agenda by putting it as an optional perinatal performance measure, the Joint Commission is signaling again. This time, the Joint Commission is speaking directly to consumers. The Joint Commission’s new “Speak Up!” campaign tells mothers they must take action by “speaking up,” if they are to be successful in realizing their preference to breastfeed.

The medium for this latest signal is a brochure. There are several things to like about this campaign’s brochures:

  • It is intended for distribution during the prenatal period when women have the opportunity to think and plan ahead.
  • Breastfeeding, while a biological norm, is presented as a skill to be learned. Learning requires preparation before, during and after birth for mother and baby
  • Women and support people are encouraged to speak up and ADVOCATE for themselves to ensure they are receiving proper, evidence-based care. In other words, being a squeaky wheel is a good thing.
  • Telling women to speak up implies that they ought not assume their hospital’s care is in line with successful outcomes.
  • The information provided is consistent with Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding and, therefore, is evidence based.

Encouraging personal responsibility is laudable. That said, my reservation with this campaign is that it requires a consumer to have a rather deft capacity to read between the lines. The target audience is unlikely to be able to do this, if they are not first informed that the current and common infant feeding support they are likely to encounter is rife with serious deficits. A more straightforward approach would be great.

I suspect, however, the greatest significance of this campaign is the signal it sends to hospitals rather than to consumers. Brochures are a rather passive form of support that may or not be read by consumers. I am confident, however, that the administrators inside hospitals who make decisions about whether or not to pursue the Baby Friendly designation are able to see this campaign in a larger context – one in which an ever-clearer signal is being sent for hospitals to link doing a better job by consumers with accreditation status. Seen in this light, “Speak Up!” is a very positive development.

— End of installment 2, final installment coming soon. Feedback appreciated!

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Part 1: Consumer Advocacy & Evidence-Based Infant Feeding Practices

Here’s the first “installment” for my upcoming presentation at the March 2-3 Breastfeeding Coalition 5h Annual Meeting. Blue text indicates information that will be placed on PowerPoint slides, black text indicates what will be said. I’d love your feedback either here or via email at motherbabynetwork@gmail.com.

This installment covers introductory info, background on me and why thinking of women as consumers rather than patients can be productive. The next installment will go into consumer demand, the Baby Friendly Hospital Initiative and the increasing support for Baby Friendly at all levels of government and among accrediting bodies.

The Role of Consumer Advocacy in Increasing Evidence-Based Infant Feeding Practice

“Mothers are acutely aware of and devoted to their responsibilities when it comes to feeding their children, but the responsibilities of others must be identified so that all mothers can obtain the information, help, and support they deserve when they breastfeed their infants.” (Surgeon 2011: v)

Good morning. My name is Katharine Gallagher. I have been invited to speak with you today about the role consumer advocacy plays in increasing evidence-based infant feeding practice. My objective is to outline how responding to consumer demand and encouraging and engaging consumer advocacy encourages hospitals and providers toward practices that effectively support women in making sound infant feeding decisions.

The framework for this year’s annual meeting is the Surgeon General’s 2011 Call to Action to Support Breastfeeding. The fundamental assertion made in this call to action is that a woman’s ability to initiate and sustain breastfeeding is influenced by a host of variables and factors. These include an individual woman, her partner, extended family, healthcare providers and employer. Public health and social service agencies as well as community-based programs also influence breastfeeding decisions as do schools, child care centers, houses of worship, business and industry, and, let’s not forget…the media.

In other words, decisions and outcomes related to infant feeding occur in a multi-layered and dynamic environment. The manner in which these multiple factors support or thwart a woman’s ability to make and follow through on infant-care decisions has a very fast-acting and mostly permanent impact on the trajectory of decisions to breastfeed.

Each of us comes to this meeting with a particular role to play in curbing the discord of the aforementioned factors that influence individual-level decisions. We are here to develop meaningful social supports to ensure women can follow through on the decision to breastfeed their babies. My focus this morning is on the inter-play between women as the consumers of infant feeding services and health care facilities – hospitals – and  providers.

Responding to demand and partnering with consumers fosters improved maternity care. It moves us closer to a model that consistently educates and supports women, families and communities to make choices supported by sound scientific research, good judgment and individual preferences and values. Once engaged, consumers provide an invaluable feedback loop to support and inform policy, practice and outcome analysis. As system users, consumers have a unique perspective. They know from experience how well a particular system is or is not working. Frequently, they know what is needed.  When this information is regularly sought and acted upon, we have a culture of consumer engagement.

About Me

Before getting started, I’d like to share a little about myself and how I came to be involved with maternity care reform as a consumer advocate.

I am the mother of two boys – ages four and six. My professional background is in public policy. My experiences over the past six years with both evidence-based and non-evidence-based maternity care have profoundly influenced me as a person, a mother and a citizen. The result is a deeply-held conviction that we must transform maternity care in this country. This is not solely a women’s issue. We are talking about reforming policies and practices as well as behaviors and decision-making approaches with major physical, emotional, social and financial implications for the economic health and security of this generation and those to come. This is an “everyone” issue.

My first pregnancy was a healthy, low-risk experience that resulted unexpectedly in what I believe to have been an unnecessary and entirely avoidable cesarean section. Hindsight is 20/20. Only in retrospect could I see the signs pointing to and hinting at the impatience and aggressive management my Ob/Gyn employed during my labor and birth. My postpartum trajectory continued south as my son and I had extreme difficulties establishing breastfeeding. However, because he was such a determined latcher, we were considered to be doing fine and encouraged to skip our lactation consultation before discharge from the hospital. This decision was made despite the telltale signs of chewing on my nipples and my too-shyly stated observations that “things didn’t feel right.” At home with a chomper-latch baby and reeling from the shock of an unanticipated surgery, hazy from painkillers, things got worse and worse still.

A long story short, my pleas for help from the medical practice I was using and a willingness to pay out of pocket failed to secure the assistance we needed. In serious need of help, during an appointment for my baby, I asked the pediatrician to look at my breasts to confirm that I had a problem. He would not, and no referral was made. A desperate late-night call to La Leche League and another pediatrician’s gentle support resulted in our finally finding someone to help. We found an independent lactation consultant who works outside the healthcare system.

By this point, all of us were in pretty wretched shape. My nipples were chewed to shreds, my son was far from content and my husband was worried. Getting back on track required weeks of pumping and syringe feeding until my breasts healed. We then slowly re-introduced my baby to the breast. This was a team effort. My husband and I both took unpaid maternity leave and my mother moved in and  took care of all of us. Weeks of perseverance paid off and eventually we were where we needed to be to continue breastfeeding. Clearly this experience is and would be the exception, not the rule for most women and families.

Pregnant again and much better informed the second time, I knew I wanted to have a different birth and postpartum experience – one that would allow me to hold and hug my two-year old and tend to a newborn without the physical and emotional challenges of cesarean recovery. I selected the Baby-Friendly designated PeaceHealth Nurse Midwifery Birth Center for my care. My prenatal experience exhibited the hallmarks of optimal healthcare – individualized care, personal responsibility, shared decision making and informed consent. Attended by a midwife at the hospital, I had an un-medicated VBAC. My second son was born content and alert and eased peacefully into life outside the womb beginning with the glorious and inordinately important but yet to be fully understood skin-to-skin time. My delight and amazement in seeing a baby so alert and present was shared by the many Labor and Delivery nurses who came in to see an “un-medicated baby.”

Consistent with Baby Friendly, I had been counseled and educated prenatally about breastfeeding. I had the knowledge and support to confidently continue nursing my first son through my second pregnancy. Per my wishes, I was also able to tandem nurse until my oldest son weaned at 3 yrs old. Furthermore, along the way I connected with other new mothers using the Nurse Midwifery Birth Center. These women became an invaluable source of support for breastfeeding and just about everything else – pumping, returning to work, not returning to work, how to take a shower, the best places in town to change diapers and the lists goes on.

Tops on our personal lists for breastfeeding success? The weekly drop-in baby clinic and 24-hour phone support for lactation. We had a  lactation safety net and while many of us had not realized it would so critical before birth, we soon discovered how necessary it is to getting breastfeeding started and maintained. We did not yet know this lactation support was the outcome of evidence-based practice or that it had a name –the Baby Friendly Hospital Initiative. What we did know was that it worked. This was a most welcome change from my first breastfeeding experience and I was continually struck by the way in which new mothers were seamlessly supported in learning to breastfeed and to solve problems and overcome challenges that are part of life with a new baby.

Consumer or Patient?

“Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming barriers to safe, effective care.” (Romano, 53) 

Just as communities, healthcare systems, government and employers must re-tool or re-orient themselves to support evidence-based infant feeding decision making, so too must those who consume maternity services – women. Seeing oneself as a consumer rather than as a patient can provoke a radically different set of perspectives and actions that positively influence individual and system-wide care.

Pregnancy is a gateway experience into the health care system for many women. For most, pregnancy is a time of health, discovery and a renewed commitment to well-being. Women’s experience shapes their behaviors and expectations for future interactions with healthcare throughout the life cycle. Add to this that women frequently take the lead in heath care decision making for nuclear and extended family members and their initial experiences via maternity care have multiple ripple effects. Accordingly, the manner in and degree to which they participate in decision making during pregnancy, birth and the postpartum period has significant social, health and economic implications in the lives of women, families and communities that reach well beyond today’s topic of infant feeding.

Re-conceiving of the users of the maternity care system as consumers rather than patients promotes productive ideas and behaviors by providers and users. Consumers are associated with:

  • Knowledge
  • Choice
  • Purchasing Power
  • Autonomy
  • Responsibility

As a consumer advocate and childbirth educator, I encourage women to take an active role in their care. I encourage them to use their purchasing power and autonomy to shop around and ask questions in order to identify facilities and practices with the best reputations for thorough lactation support with excellent post-birth outcomes. I remind them that it is okay to change hospitals, birth centers and providers, too.

When women are seen as and view themselves as consumers with the attributes of knowledge, choice, purchasing power and autonomy, it is much easier to develop and benefit from the resulting personal responsibility, mutuality, partnership, collaboration and trust when they engage care in a particular setting. This beginning orientation lays the groundwork for developing the expectation for and demand for consistent evidence-based practices. It lays the anticipatory groundwork on the part of the user for share decision making and informed consent across the life cycle.

These assertions have yet to be borne out by research. The majority of current maternal and child health research focuses on interventions fully within the realm of providers with little to no consumer participation. Cesarean surgical techniques or intensive care treatments are examples of “provider realm” interventions. Research into consumer-realm interventions would invert institutional paradigms to elevate women receiving care to the position of  a “positive” and “powerful” actor capable of moving maternal and child health outcomes in a positive direction. In this era of health reform in which we appear to be searching for meaningful ways to move toward a preventive model with the associated reduced costs, increased positive outcomes and great consumer satisfaction, this type of inquiry is much needed.

We are seeing hints of this forward-thinking inversion here in Oregon. During the last legislative session, a law was passed directing the Oregon Health Authority to investigate how doulas (labor companions) improve birth outcomes for women at disproportionate risk. Doulas provide emotional, non-medical support associated with positive outcomes. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period. Rep. Tina Kotek (D-N and NE Portland) and Rep. Lew Frederick (D-NE Portland) sponsored the bill. Portland-based International Center for Traditional Childbearing played a critical role in the introduction of the bill.

Fortunately, there is one very important “consumer realm” intervention for infant feeding services that has already clearly demonstrated massive maternal and child health benefits.. It is the Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding. From start to finish, consumers are educated, engaged in decision making with the necessary evidence-based information about infant feeding and provided with full-spectrum perinatal support for making breastfeeding work. This intervention can be summarized in two words: “It works!” It works for mothers, families, employers, communities, economies and, well, everyone. Baby Friendly figures greatly into any discussion, including this one, of policy development and implementation for heeding the Surgeon General’s Call to Action to Support Breastfeeding.

End of installment #1…..

Decisions About Infant Feeding Do Not Happen in a Vacuum – Context Matters

In celebration of its 50th anniversary, Oregon Research Institute recently hosted a public lecture – “Addressing the Nation’s Crisis with Nutrition and Obesity” – by Kelly Brownell, director of Yale’s Rudd Center for Food Policy and Obesity. In the past several years, obesity prevention has gained enough traction to be a well-established national health priority. Public and private funders are actively looking for solutions to cut down on the enormous and growing costs of addressing the innumerable diseases and suffering associated with and exacerbated by obesity.

Curious to see if breastfeeding would figure into the lecture, I attended…

What’s the connection between obesity reduction and breastfeeding? Breastfed children experience lower rates of obesity than do formula-fed babies. Why? “Scientists do not know exactly why… Some people think that a breastfed child can better control how much he or she eats and so may become accustomed to eating less than a bottle-fed child… Also, babies who are breastfed have lower levels of insulin, a hormone that promotes fat storage.”

Because breastfeeding is associated with better outcomes, it, too, is enjoying newfound traction in policymaking circles. Oregon’s one-a-kind insurance collaborative – Oregon Health Insurers Partnering for Prevention (OHIPP) – selected breastfeeding as its first intervention intended to reduce obesity. Nationally, Michelle Obama promotes breastfeeding as part her campaign to reduce childhood obesity.

A well-known recent study reports that 911 deaths, mostly among infants, could be averted and $13 billion per year saved, if 90% of US family could follow medical recommendations to breastfeed exclusively for six months. Nine in 10 Oregonian women initiate breastfeeding. This number declines rapidly so that at six months, 2 in 10 babies are exclusively breastfed.

After establishing obesity as a global epidemic of the first order, Kelly focused his lecture on reduction and prevention in the United States through meaningfully addressing the manufacture and sale of the foods and beverages fueling today’s ghastly health outcomes. Breastfeeding was not discussed. However, the ideas and suggested pathways to obesity reduction that Kelly sketched out are well suited to the development of strategies for reforming the inadequate breastfeeding support models currently accessible to most women and babies here in Lane County and elsewhere.

…reform comes when the environment in which individual choices are made is geared to support rather than thwart decisions that align with healthy, positive outcomes…

Reform: Clean Up for Infant Feeding Models

Brownell argues that real reform comes when the environment in which individual choices are made is geared to support rather than thwart decisions that align with healthy, positive outcomes. Currently, models to promote well-being, whether for nutrition or infant feeding, exist within an environment that encourages behaviors associated with poor outcomes. Today’s decision-making environment for infant feeding is shaped by legislation, regulation and economic prerogatives that promote and protect the interests of manufacturers and non-evidence-based practices at the expense of individual, family and community wellbeing. The current “default settings,” as Kelly refers to them, run counter to science, transparency and good health practices.

In this kind of “toxic” decision-making environment, Brownell describes the disproportionate responsibility individuals bear in becoming educated and motivated to identify evidence-based or effective care and accessing it.  Current default settings put consumers at so great and extreme a disadvantage in making informed decisions that it is unreasonable to expect improved outcomes to result from individual responsibility alone. In other words, individuals are “thrown to the wolves” and then summarily blamed for making the wrong decision – all in the name of personal responsibility.

What is needed to address an asymmetrical and toxic decision-making environment? The default settings must be reset to optimize individual decision making and public well-being. Legislation, regulation and economic practice must be redirected to protect and reward practices that promote rather than undermine individual and national health and economic well-being.

Anyone following funding for Women, Infants and Children can see the power of formula company interest groups on full display. Through costly and effective lobbying campaigns, these companies succeed in shaping national policy for their own benefit and at an extraordinarily high cost to everyone else. These companies create the toxic environment in which WIC is cornered into purchasing and providing formula rather than evidence-based infant feeding support systems. To think the nation’s most vulnerable women and children bear responsibility for allowing this to happen is ludicrous.

Shifting a decision-making environment to empower choices in line with good health and economic outcomes is not a new idea. Before obesity reduction and breastfeeding promotion managed to make it onto the national agenda, other examples abound in which default settings have been positively reset. Smoking cessation and tobacco regulation is just one, good and well-known example. Another example? Air bags. All new cars now come equipped with them but this wasn’t always so. Having one or not is not a private but a public decision. This idea is so firmly supported by legislation and regulation that buying a new car without one is impossible.

Improvement looks like…

What if default settings for infant feeding were optimized to serve the nutritional and economic interests of women, babies, families and communities? Here are few ideas for what a non-toxic environment would look like….

  • Evidence-based breastfeeding models of care in hospitals and birth centers
  • Higher reimbursement rates for evidence-based facilities and providers
  • Universal access to early and comprehensive prenatal care
  • Access to evidence-based childbirth and breastfeeding education as part of prenatal care
  • Effective employer-based supports systems to support breastfeeding mothers

In Lane County, there are positive signs of increased access to evidence-based breastfeeding models. Sacred Heart Medical Center is pursuing the Baby Friendly Hospital Initiative designation for evidence-based care. McKenzie Willamette Medical Center reports being in the midst of internal discussions about a similar commitment to mothers and babies in our community. The PeaceHealth Nurse Midwifery Birth Center is already one of Oregon’s five designated facilities. See what women who access breastfeeding care have to say about Baby Friendly care – read A Consumer Survey on Baby Friendly Breastfeeding Services.

Better Breastfeeding Services in the context of CEOs, Grandmas and Formula

On Monday, I attended and participated in a panel discussion at the Moving Communities Toward Evidence Based Breastfeeding at St. Charles Hospital in Bend. The conference was the result of a productive collaboration between Oregon WIC, the Central Oregon Breastfeeding Coalition and St. Charles. Dr. Marianne Neifert was the conference speaker.

Moving Communities Toward Evidence Based Breastfeeding reflects growing awareness among consumers, healthcare providers and government agencies of the need to implement breastfeeding practices inside hospitals that effectively support women and infants to initiate breastfeeding. Ineffective practices including failure to assess proper latch, formula supplementation and inadequate follow up after birth undermine the long-term prospects for women and infants to establish an adequate milk supply. In other word, the days of “you can breastfeed when you go home” must end.

Kudos to Desiree Nelson, WIC Project Coordinator for the Improvement of Maternity Care Practices, for organizing the conference and to St. Charles for making it possible by hosting. I had hoped this conference would be held in the Eugene/Springfield areas as there is considerable buzz “on the street” that Sacred Heart Medical Center is seriously considering becoming a designated Baby-Friendly facility.

The panel discussion in which I participated included consumers (myself and another woman from Bend), doctors, a hospital administrator and a WIC employee. The composition of the panel modeled the kind of stakeholders conversation needed throughout the state to encourage the adoption of sound breastfeeding practices. (Many thanks for including consumers in the discussion.) As consumers, we described the long-term effects receiving non-evidence based care had on initiating breastfeeding. We described the enormous difficulties of accessing lactation expertise inside and outside the hospital as well as the difficulties of being encouraged repeatedly to formula feed despite making the preference for breast milk known. Like so many other women, our expectations for breastfeeding support were not matched by the services provided.

Three great terms

Three particularly descriptive terms were used during the conference. They describe the difficulties proponents for better mother- and baby-care must contend.

CEO Hurdles. These hurdles refer to business concerns that can conflict with optimal health care for women and babies. For example, designated Baby-Friendly hospitals do not accept free formula. Convincing management that this is not only the correct decision but also one that will not compromise market share is, to put it mildly, challenging. Perhaps as increasingly savvy consumers and government agencies come to see and describe free formula as cheap swag, this hurdle can be cleared.

Block Party. This refers to the trend toward having large numbers of family and friends in the delivery room who are unfamiliar with how breastfeeding is most well supported. In the absence of this information, the clamors to see and hold a new baby frequently trump mother and baby skin-to-skin contact. Nurses and lactation specialists commented on how hard it is for them to protect the mother-baby window for bonding. In the absence of prenatal education about the role of  skin-to-skin contact for breastfeeding, nurses have a hard time diplomatically helping make this happen. After all, who’s going to tell grandma she can’t hold the baby just yet?

Mamatoto. This is a Swahili word for the mother-baby unit. Keeping mothers and infants together is the best way to encourage a good start for breastfeeding. We don’t have this word in English but we need one. My answer is to make it happen by putting “mother” and “baby” together to make “motherbaby.”

Moving Forward from the Middle

Moving Communities’ strength was in its devotion to equipping participants with the knowledge and encouragement to move their respective organizations toward sound breastfeeding practices even in as they contend with CEO hurdles on one end and grandmas who likely did not breastfeed and have yet to have a chance to learn how to be supportive at the other end. It’s a tall order.

Dr. Neifert spent a great deal of time describing the development and implementation of Colorado’s Can Do 5 program. This program serves as a useful tool for moving healthcare facilities and providers toward evidence based breastfeeding practices. Can Do 5 is useful because:

  • It’s an intermediate subset of steps on the way to becoming Baby-Friendly. (Many administrators and staff see Baby-Friendly designation as a daunting starting objective, especially in light of CEO hurdles.)
  • It represents incremental changes fundamental to positively promoting long-term breastfeeding success for families.
  • It generates momentum among management and staff as positive outcomes and familiarity with new practices increase. With these steps accomplished, it is much easier to take the additional Baby-Friendly step of refusing free formula from manufacturers.

So, what is Colorado’s Can Do 5?

The “Can Do 5” program is the result of analyzed data from the 2002 and 2003 Colorado PRAMS surveys having been presented to hospital staffs and administrators. The PRAMS survey is a population-based surveillance system for identifying and monitoring behaviors and experiences of women before, during and after pregnancy. Questions regarding hospital breastfeeding practices were added in 2002. These “yes” or “no” questions roughly mirrored the Baby-Friendly Ten Steps:

  1. Hospital staff gave me information about breastfeeding
  2. My baby stayed in the same room with me at the hospital
  3. I breastfed my baby in the hospital
  4. I breastfed my baby in the first hour after my baby was born
  5. Hospital staff helped me learn how to breastfeed
  6. My baby was fed only breast milk in the hospital
  7. Hospital staff told me to breastfeed whenever my baby wanted
  8. The hospital gave me a gift pack with formula
  9. The hospital gave me a telephone number to call for help with breastfeeding
  10. My baby used a pacifier in the hospital

The survey response rate was at least 70% each year and results were weighted accurately to reflect all Colorado mothers.

Survey says….

Colorado found that five specific hospital practices were significantly associated with longer durations of breastfeeding:

  • Baby breastfed in first hour (72%)
  • Baby stayed in mother’s room (93%)
  • Baby fed only breast milk (46%)
  • No pacifier use in hospital (46%)
  • Given phone number to call for help (84%)

The average number of practices reported was 2.8 and less than half of babies left the hospital without being supplemented or given a pacifier. Just one in five mothers reported experiencing all five of these supportive practices. But what a difference this made for these mothers and babies! Two-thirds  (68%) of this group were still breastfeeding at 16 weeks, compared with half (53%) of those who did not get all five practices. Of particular interest? Breastfeeding rates for this group were consistently higher for women below, at and above the poverty level – EVERYONE benefited.

2 months (wk 9) 4 months (wk 17)
All mothers yes = 80%, no = 64% yes = 63%, no = 48%
Medicaid yes = 66%, no = 47% yes = 47%, no = 35%
High Socioeconomic Status yes = 90%, no = 78% yes = 78%, no = 61%

Yes = got all 5 practices

No = did not get all 5 practices

See the 2007 published findings at www.cdphe.state.co.us/ps/mch/gettingitright.pdf

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Formula Company lobbyists hard at work

In response to today’s Washington Post article, Lobbying fight over infant formula highlights budget gridlock, I sent the following letter to the editor:

Thank you for bringing to light the latest scam perpetrated by formula companies against the country’s most vulnerable women and children. Under the aegis of improved efficacy, they seek to force more expensive formula on WIC in the absence of any evidence of increased benefit for babies.

That formula companies and their lobbyists try to block efforts for FDA due diligence by suggesting it is racism or the work or ideological “lactivists” would be funny, if only it weren’t so effective.

There is good news. Some state WIC programs, including that of my home state of Oregon, are daring to meet their clients’ needs and honor their rights. How? By recognizing the impossible barriers to informed feeding choices that they face before they ever make it to WIC. Most hospitals’ infant feeding practices guide women to formula before they go home. You’re right – it’s not about breastfeeding, it’s about profit.

Here’s hoping Oregon WIC and other state WIC programs will continue demanding the level of care all families deserve. Let’s hope elected officials and lobbyists promote rather than quash a move to bolster mother- and infant-health.