Preventing Culturally Induced Lactation Failure

281How often does it happen that women truly are physically unable to breastfeed?

No one actually has a solid answer to this question. The common estimate is a very hazy, “less than 1%.” I’ve said it, very hazily, plenty of times myself. But, what does that really mean? I’ve certainly talked with a lot of struggling mothers over the years—many of whom go on to continue to breastfeed successfully, but who might very well not have done so without encouragement, reinforcement, and practical suggestions. If they never reached out for help, might they have ended up as part of that semi-mythical 1%? How about those mothers that absolutely stagger me with their ability to keep going and keep trying when I would understand completely if they decided to quit and in fact question that I, personally, would have been able to continue if faced with the same obstacles—where do they fit in? Maybe just in the category box labeled amazing.

Yesterday, I read an article on the Breastfeeding Medicine blog that really shook my personal framework up a bit:

…I would argue that there’s a very fine line between “sensationalizing” and “truth in advertising.” Reproductive biology is imperfect — some couples can’t conceive, and some pregnancies end in miscarriage or stillbirth. The silence around these losses and the isolation that women have historically experienced has probably worsened the suffering for many women. On the other hand, emphasizing these risks and creating a culture of fear harms the majority of mothers who will have successful pregnancies and births.

Lactation is probably a few decades behind infertility and pregnancy loss in coming “out into the open” as a generally robust, but not invincible, part of reproductive biology.

via Establishing the Fourth Trimester « Breastfeeding Medicine.

Wow! Brain boggled in reading this. Heart clenched at thinking that I may have treated someone as casually in breastfeeding loss as other mothers have been treated over and over again in pregnancy loss. The author goes on to explain that women used to be blamed for having miscarriages and we just might be doing the same thing to women who physically can’t breastfeed. I have never in my wildest dreams considered adding “lactation failure” to my understandings of the things that can truly go wrong during the childbearing year. I usually consider, “some mothers are physically unable to breastfeed” to essentially be in the same territory as dragons and unicorns. I’ve remained firmly convinced for, like, ever, that it is culture that fails mothers and babies and not women’s bodies that fail. And, I truly wonder if it is ever possible (except for in cases of insufficient glandular tissue, metabolic disorders, breast surgery/removal, and clear physical malformations) to really tease apart whether a mother is actually experiencing lactation failure or sociocultural failure. I remain fairly convinced that in many cases it is impossible to know—but, that a mother (or physician) may certainly experience it as “lactation failure” and thus add that data point to the 1%. I have long maintained that a lot of people forget that breastfeeding occurs in a context and that context doesn’t necessarily support breastfeeding. However, I do also know from years of experience that motherbaby physiology can lead to problems too and we often overlook that in assertions about breastfeeding.

How do we get breastfeeding off to a good start?

At our 2011 Big Latch On event.

At our 2011 Big Latch On event.

How do we make sure that mothers do not experience sociocultural breastfeeding failure? It begins with the birth. Birth and breastfeeding are not discreet events—they exist on a biological continuum. When I attended the La Leche League International conference in 2007, there was an exciting emphasis on “the motherbaby” as a single psychobiological organism. The womb is the baby’s first habitat and following birth the baby’s “habitat” becomes the mother’s chest—otherwise referred to as “the maternal nest.” In short, a normal, healthy, undisturbed birth leads naturally into a normal, healthy, undisturbed breastfeeding relationship. Disturbed birth contributes to disrupted breastfeeding. In a previous article on this topic I wrote:

New mothers, and those who help them, are often left wondering, “Where did breastfeeding go wrong?” All too often the answer is, “during labor and birth.” Interventions during the birthing process are an often overlooked answer to the mystery of how breastfeeding becomes derailed. An example is a mother who has an epidural, which leads to excess fluid retention in her breasts (a common side effect of the IV “bolus” of fluid administered in preparation for an epidural). After birth, the baby can’t latch well to the flattened nipple of the overfull breast, leading to frustration for both mother and baby. This frustration can quickly cascade into formula supplementation and before she knows it, the mother is left saying, “something was wrong with my nipples and the baby just couldn’t breastfeed. I tried really hard, but it just didn’t work out.” Nothing is truly wrong with her nipples or with her baby,

I know that my birth experiences significantly impacted my breastfeeding experiences in that my babies were never separated from me after my peaceful, undisturbed births (one birth center, two homebirth). They went directly from being born to my breast, keeping the physicality and continuity of our relationship unbroken and undisturbed. That is not to say that we never experienced any challenges, I struggled with oversupply with all of them—which reminds me of attending another LLL conference presentation by Diana West in which she stated that she is seeing much fewer “normal course of breastfeeding” issues in her practice and instead of noticing an “epidemic of both low milk supply and oversupply.” She asked the room if we were noticing the same thing and many of us raised our hands. One possible theory is the amount of endocrine disruptors in our food supply. Again, is that actual lactation failure or is that ecological failure?!

Some time ago I wrote an article for the Friends of Missouri Midwives newsletter in which I asked for submissions regarding the topic of how birth experiences impact breastfeeding. A doula wrote to share her experiences:

My births definitely affected my breastfeeding experiences. I prepared extensively for my first child’s birth. I felt fully educated about birth and also breastfeeding. I planned and had a natural birth. Being empowered by that helped me know I could handle and be successful at breastfeeding too. My two unassisted births were “all me”. There was no one telling me what to do. I was confident in that and that also helped build my confidence one again in breastfeeding. I will also go on to say that not only did my natural hospital birth and subsequent home births help in breastfeeding, but also generally as a mother. They empowered me to know that I was capable of a lot more than I could ever imagine! (Which is great on a day with three little ones screaming around the house!)

 And, a local physician also had input about the question:

Gosh, my own experience–how can I know how my birthing influenced my breastfeeding?  Since the nursing part was so easy, and I birthed at home (thank heavens), well, how would I know if it would have been different if we had done it differently?  But I know this:  it is SO much easier being a breastfeeding supportive physician to home born babies than it was trying to support breastfeeding when the birth was distorted.  In my experience, the only other thing that makes that much difference is La Leche League attendance.  I think mothers and babies are designed to experience labor and birth and then breastfeed.  When things go differently–like when labor is started early for some reason, or when mothers don’t get to experience their labors and births because of epidurals or other drugs or cesarean  sections, then the breastfeeding is more likely to be challenged.

Babies are programmed to learn to nurse in that first hour after birth.  They need to be in contact with their mothers for that time to do that.  It doesn’t take much intervention to undermine that.  Our babies are working so hard, learning to live on the outside of the womb–changing everything, including their breathing, their circulation, their digestion, elimination, integrating new and overwhelming sensations–and also learning the complex skill of finding the nipple, grasping the nipple, holding the nipple, milking the nipple (and don’t forget to swallow and breathe!).  We should leave them alone and not ask them to do one more thing–like meet Grandma, or deal with the nurse, or warm back up from a bath.

So here’s my advice:  If you want to breastfeed and do it effortlessly:

1.  Get great prenatal care from the best midwife you can find

2.   Plan and achieve a home birth

3. Go to La Leche League regularly during pregnancy and nursing.

This doctor then wrote back to me again with some additional comments about breastfeeding and La Leche League:

La Leche League makes a BIG difference.  In my experience, mothers who are members have far fewer reasons to call me for advice (of any kind, really).  And when they do, they tend to be focused, easy-to-answer questions or requests.  So, instead of “my nipples hurt,” it is, “I’ve been reading/talking to/consulting with various sources and I think that I have nipple thrush.  The things I have tried haven’t worked and I am not ready to try Nystatin.  Can you prescribe this for me?”  LLL ladies ROCK!

I am convinced that a thousand little adjustments get made in the wise nursing circles–a comment made, a slight modification of a nursing  position, an encouraging word, a question asked, a behavior modeled.  With these gentle, under-the-radar moves, nursing just gets easier or stays easy.  The woman and her circle never consider that a “nursing problem” existed.  No big intervention needs to happen.

Without these “interventions” nursing problems DO develop, and then the rescue team gets called in–people have big feelings, do big or little interventions, they help or they don’t and people feel like heroes or failures and “breastfeeding problems” get into the story-telling.  But what gets lost is how easily these things are “prevented”.

Midwifery is like this.  Parenting is like this.  Life is like this.

I really appreciate her closing observations here about wise nursing circles. I believe it can be in these circles that we find the women who know and we can certainly give each woman who we come into contact with the best chance at preventing or overcoming culturally induced lactation failure.

11 thoughts on “Preventing Culturally Induced Lactation Failure

  1. “I usually consider, “some mothers are physically unable to breastfeed” to essentially be in the same territory as dragons and unicorns. I’ve remained firmly convinced for, like, ever, that it is culture that fails mothers and babies and not women’s bodies that fail. And, I truly wonder if it is ever possible (except for in cases of insufficient glandular tissue, metabolic disorders, breast surgery/removal, and clear physical malformations) to really tease apart whether a mother is actually experiencing lactation failure or sociocultural failure.”

    But aren’t all those women – the ones with IGT, metabolic (& endocrine) issues, breast surgery/injuries, and hypoplasia – the ones this article is about? These women are not ever getting worked up or diagnosed with their issues. They get the message that since they have no “official” diagnosis (and I would argue the science isn’t there yet in a lot of cases to have a good diagnosis for some women) then their failure is “sociocultural” and they are not trying hard enough/didn’t go to LLL/should have had a home birth/etc. I am not disagreeing with you at all that these things make a huge difference and that most of breastfeeding “failure” does originate with poor social support, birthing practices, etc. But when we demand that a woman have a diagnosis, we are asking for something that is almost unicorn-like, because there are so few breastfeeding-knowledgeable health care providers and so few solid diagnoses at this point.

    • Absolutely! And that was my epiphany when I read this article–if I assume that true physiological lactation failure is so rare as to be almost impossible, what have I been missing/overlooking/not understanding with the mothers I work with. But, part of the reason I feel that way–that it is unicorn like–is because of how often sociocultural failures are lumped in or described as physiological “failures” (I actually hate using that word with regard to any mother. Sorry! 😦 ) and so it becomes almost impossible to know what is going on and how to best help and it kind of just goes around and around…

  2. Hi – thanks for reading and linking to my blog. I agree that it’s really, really hard to disentangle “biological” vs “cultural” vs “ecological” reasons that breastfeeding comes undone for moms — and it’s critical to sort the causes out if we want to figure out how to prevent such problems in the first place. At the same time, though, for the mom who desperately wants to breastfeed and hits a dead end, it doesn’t really matter. We need to validate her experience and help her to grieve the loss of the breastfeeding relationship that she had anticipated. The loss is real, whether it’s biological or sociocultural.

    When a mom comes to a lactation specialist in anticipation of another birth looking for ways to optimize her chances, that’s a great time to talk about ways to minimize interventions during birth, seek out social support from circles of nursing mothers, and develop a “game plan” to get breastfeeding off to a great start. However, having that conversation when mom is in the thick of “lactastrophe” is a bit like telling a woman having a miscarriage, “Don’t worry, you can always have another one.”

    I also agree that birth interventions can adversely affect breastfeeding. Unindicated inductions of labor, routine separation of moms and babies, and elective formula supplementation can all affect whether moms are able to achieve their breastfeeding goals. But again, it gets tricky to tease out when an obstetrical intervention messes up breastfeeding, vs. when a pregnancy complication leads to intervention and adverse outcomes. A mom with severe preeclampsia at 36 weeks will undergo a long induction of labor — leading to a late preterm / early term birth a baby who has immature oromotor skills and lots of breast edema, all of which can make breastfeeding difficult. This is not a mom who could safely await spontaneous labor and have a home birth. So is this a biological or cultural set-up for breastfeeding problems?

    I know that I have a skewed view of these issues, because I am a high-risk obstetrician, and I see the sickest mothers during pregnancy. Moreover, I work in a community of incredibly skilled lactation consultants, and they fix all the straightforward breastfeeding issues. I see only the “unicorn” mother-baby dyads who continue to struggle despite tremendous resources and support.

    But these unicorns are real, and I spend a great deal of time helping mothers to come to terms with the fact that breastfeeding is not invincible, and that they are not personally culpable for the fact that they have not been able to realize their breastfeeding intentions. We talk a lot about why she wanted to breastfeed, and how to translate as much of her original intent as possible into a mixed-feeding or bottle-feeding relationship with her baby. And we touch on the fact that each baby is different, and with another birth, the story could change completely. I also find that many moms whose intentions are derailed have symptoms of postpartum depression, and I work closely with our perinatal mood disorders center to provide moms with counseling, support and medication, as needed.

    You and I are entirely on the same page about the cultural context in the US and the current profound lack of support for breastfeeding moms. We have a tremendous amount of work to do to build a breastfeeding culture. But we also need to validate the experience of those who are caught in the biosociocultural crossfire and help them to make peace with their breastfeeding experience.

    • Thank you for commenting! And, yes, while this post ended up going to how do we *prevent* culturally induced lactation failure from occurring (not armchair quarterbacking an already ended breastfeeding relationship), I really, really appreciate the points you raised for me in how to compassionately support women when the relationship ends for whatever reason. I was glad that someone posted a tweet in response to this post letting me know that she felt very *heard* and treated with compassion by me when she shared her own breastfeeding loss experience with me (12 years post-experience). So, I guess I’m doing all right! I’ve been doing breastfeeding counseling for 8 years and I’ve seen a lot of complicated situations–I’ve previously written that I’ve actually more often marveled that a mother has *kept going* than I have wondered why she quit.

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