Wednesday, October 15, 2008

Breastfeeding and Poverty: An Ounce of Prevention

When I saw the Motherwear Breastfeeding Blog’s October Carnival topic was breastfeeding and poverty, I knew I had to interview my friend Kim Paschal. She is the breastfeeding coordinator at our local health department and has helped countless low-income moms and their babies build successful breastfeeding relationships. Our entire interview is posted at the end of my article, because I know you’d like to read it. I went into it with an opinion (of course) and came out with a different one. Be sure to read the posts at the other participating blogs, which are listed at the bottom of this post.

Breastfeeding and Poverty: An Ounce of Prevention

The topic of breastfeeding and poverty reminds me of a new mother my coworker saw some time ago. (I work in a mom-baby boutique where we rent hospital-grade Medela pumps and also sell a selection of single-user ones.) It was a Saturday. The mom was breastfeeding but didn’t think the baby was getting enough milk. She wanted to pump to see how much milk was coming out, so my coworker started going over prices with her. $70.00 to rent a Symphony for a month? No way. It was only $15.00 to rent a Lactina for a week, but it cost $45.00 for the kit to go with it. Even the manual Harmony pump cost $30.00, and this mom did not have it. The lactation consultant at the hospital was off for the weekend and we had no baby scale, so doing a before-and-after weighing was not an option. She could probably have gotten a pump from the health department for free, but it was the weekend and, as is generally the case, she needed the pump yesterday. It’s heartbreaking to turn moms like this one away. Most of them are probably producing a fine amount, but many end up switching to formula because they can’t prove it to themselves. If this had happened to me—and we are by no means rich—I would have snapped up whichever pump I thought I needed to feed my baby and taken the money out of savings to pay for it.

My knee-jerk reaction to this dilemma was that the government should spend more money to buy pumps for all low-income breastfeeding mothers. After all, they finance the formula. From a financial standpoint, buying a pump instead makes more sense because formula-fed babies are sick more frequently, and hospital stays paid by Medicaid cost the government a fortune!

Before I spoke with Kim I didn’t realize how supportive South Carolina actually is when it comes to funding breastfeeding. They do provide hospital-grade rental pumps for mothers who need them, although often the demand exceeds the supply and some mothers get waitlisted. First priority is given to mothers of preemies, multiples, and other special needs babies. They even give electric single-user pumps, such as the Medela Pump-in-Style, to mothers who are exclusively breastfeeding and returning to work. According to Kim, these improvements were made after studies showed what a positive impact they had on breastfeeding rates in other states. A breastfeeding mom also gets extra food vouchers through the Women, Infants, Children (WIC) program to bolster her milk supply. What more could we ask?

Well, I’ll tell you. Kim confirmed my opinion that the greatest obstacle for low-income women who want to breastfeed is lack of support from their doctors, family, and friends. Actually, that’s putting it nicely; one might even call it sabotage. Kim explained a common scenario:

For instance, a mother is not making enough milk and the physician tells her she needs to supplement, but when you talk to the mother she was only nursing a newborn 4-5 times a day and she needs to be nursing more often. She’s in a dilemma: do I trust my doctor or this lady? There are some doctors who tell a mother her milk isn’t good enough because her baby is nursing every two hours. In reality, many babies need to nurse that often. We tell the mother it’s normal, but her doctor has said her milk isn’t sufficient and it’d be best if she would quit.

A friend even told me of a physician’s assistant who presumed to tell her it was useless to breastfeed her then seven-month-old baby. She hadn’t asked his opinion, and was actually in need of medical advice for a completely unrelated issue. The PA asked “doesn’t he have teeth?” and proceeded to explain to her that breastfeeding was only beneficial for the first three months. You would think with all that education under his belt he’d have learned better!

Unfortunately, doctors remember who schmoozed them during a free lunch, gifted them hundreds of dollars of free formula for work and home, and provided goody bags for their patients. To make matters worse, doctors and nurses are frequently not up-to-date on their knowledge of breastfeeding. Unless a doctor has had a positive personal experience with breastfeeding, it is unlikely her patients will receive up-to-date information and support.

While pumps and benefits for moms are unquestionably helpful in certain situations for preserving breastfeeding relationships, I think it would help even more to educate doctors, nurses, and hospital administration. Unfortunately, it is expensive and unfeasible to change the way an entire culture of health professionals view breastfeeding. Because there is little money to be made in lactation support and a fortune to be made in the artificial baby milk industry, lactivists don’t have a snowball’s chance of wooing hospitals away from the formula companies. Most hospitals are not about to refuse the freebies formula companies offer, even though studies have shown that freebies given to new mothers hurt patient breastfeeding rates. Even if hospital administration decided to ban formula bags, it would not change the antiquated opinions so deeply ingrained in the minds of some health professionals. These opinions took years to form and they are not going to change in a day.

Instead of focusing time and money on changing the healthcare industry, I propose it would be better to work on changing the way the next generation views breastfeeding. It would kill two birds with one stone: for the short term, prospective new moms would get education and support; for the long-term, future doctors, nurses and healthcare providers could get a head start learning the latest breastfeeding information.

Among mothers who want to breastfeed, a lack of education frequently leads to mistakes such as deciding to unnecessarily bottle-feed pumped breastmilk. Many mothers have a hard time believing that the best way to feed their babies is to simply nurse. Sometimes the latch is problematic and rather than fix it the mother decides to pump exclusively, and other times the mother is convinced that the feeling of the baby sucking on her breast will have too sexual a connotation. I met one couple who wanted to breastfeed and had enough milk, but decided to exclusively pump. They didn’t technically need a pump, and since the health department was running low they had to pay out-of-pocket to rent one. After a month or two this became too expensive, so they switched to formula. They had decided to pump because it was “easier at night.” This is something I cannot fathom, having nursed my daughter in bed while I was half asleep for the past 16 months. If only someone had taught that mom the side-lying position for breastfeeding!

Even when a family receives a free pump from the health department, pumping exclusively is not an attractive setup for the long haul. I look at it as triple-duty. You first have to sterilize your bottles and equipment, then you pump, and then you feed the baby the bottle, whereas women who nurse their babies only have one step: put the baby to the breast. In most cases, the chore of exclusive pumping takes its toll on the well-being of a mother (particularly if she must pump during the night), which is why most of these moms come nowhere close to giving breastmilk for the recommended first year. This happens to far too many low-income moms, and it is due to a lack of confidence and education.

Kim gave some insight into why mothers might not even want to try breastfeeding. She frequently hears sentiments such as “I don’t think I’ll be able to do it because I don’t think I’ll make enough milk.” Self-confidence is so important for a breastfeeding mom. If she doesn’t believe she can produce enough milk, she is likely to attribute every little difficulty her baby has to breastfeeding. If the baby is slow to gain, for instance, it must be because her milk isn’t “good enough,” when in reality it could be a bad latch or that the baby isn’t breastfeeding as frequently as necessary. Kim explains it this way:

They just do not believe in themselves. They have a self-esteem problem. They don’t know it, but they do. They can be so adamant and seem so confident about using formula, but when you question them about it, they are really concerned about not being adequate enough for their babies.

I think it’s likely that many of these moms, especially the younger and less-educated ones, have had lifelong issues with low self-esteem. Some of them may have even become pregnant at too young an age partly because of these issues. Kim pointed out that married women and women in college are more likely to breastfeed. Women who go to college and get married before having babies have years to mull things over and build philosophies of how they’d like to parent, even if they never have any education on breastfeeding in particular. Breastfeeding was never discussed at length in any of my college classes. However, I did take several sociology and psychology classes which cultivated my ideal of how a family should function—and that came to include breastfeeding. By contrast, women who are thrust into motherhood at a young age want to be good mothers, but may not be sure what that entails. Therefore, they take the advice of their doctors, families, and in some cases peers. If these people are not committed to supporting and promoting breastfeeding, the mother may be too unsure of herself to try it. As Kim pointed out, she does her best to keep moms encouraged, but it is usually not enough when a mom’s doctor and most of her family is working against her. A mom with low self-esteem is likely to submit when the doctor suggests weaning for the good of the child; a confident mother might act on her maternal instincts, shrugging off bad advice or seeking a second opinion.

At this point, at least in South Carolina, I think more money should be spent on early breastfeeding education rather than offering more pumps and other benefits for nursing moms or attempting to win over the healthcare industry. Actually, better education could render pumps completely unnecessary for many moms. For example, if every mom knew to refrain from giving her baby a pacifier or supplemental bottle, it would prevent nipple confusion in many babies—a common reason why moms decide to pump and bottle-feed.

I think high school would be the perfect time to introduce in-depth breastfeeding education, with mentions and general exposure sprinkled throughout elementary and middle school. While girls would not retain every detail (although the ones who become pregnant at a young age might), it would lay a foundation on which they could build for years until they became mothers. Besides, most low-income women do not attend college. If women do not learn about breastfeeding in high school and do not go to college, when, exactly, are they expected to learn about it? Ideally, I’d like to see a volunteer lactation educator invited each semester to spend at least one class period speaking to the students. I say this because many health teachers are men, and even those who are women probably have a meager understanding, at best, of this subject. A lactation professional would be able to speak in-depth about the latest information and answer questions confidently. She would also be well-networked and would know where to direct young women for various types of support. This would be inexpensive to implement and would only require a policy change.

Low-income women who breastfeed in South Carolina are, in fact, encouraged and rewarded. Most of the problem is a lack of education, or even exposure, which would be cheaper to apply than some of the steps previously taken and would, I feel, have an even greater impact. An ounce of prevention is worth a pound of cure. Many doctors have already made their minds up about breastfeeding, and most hospitals are not willing to sacrifice freebies from formula companies to increase their breastfeeding rates. However, if teenagers were routinely educated in the basics of breastfeeding, it may lay the foundation for the rest of their lives. The next generation of mothers would probably be more apt to try breastfeeding and the next generation of health professionals would be more likely to promote it.


Interview with Kim Paschal, Breastfeeding Coordinator
at our local Health Department

What are your responsibilities as breastfeeding coordinator? I assist mothers in getting babies latched to the breast, answer questions about increasing milk supply--anything breastfeeding related. There is another lady for Oconee County, but I see all Anderson County clients. I also teach classes through WIC (Women, Infants, Children).

How did you come to specialize in lactation support? It wasn’t what I thought I would be doing. I started out as a WIC clerk. I nursed my two boys and at the time the job came open, my oldest was 9 and my youngest was 5. I had worked in WIC for 9 years and I didn’t even know I was qualified. A co-worker was going to do interviews for the breastfeeding coordinator position and I commented that I wished I could do something like that. I had always encouraged women who came through the WIC office to continue to breastfeed. She said “Oh, Kim, you could, because you have a bachelor’s degree.” At that time, a bachelor’s degree was all that was required, and I had one in music. Now you have to have a bachelor’s degree in some type of science. I applied and got the job. I was the only interviewee who had children and experience breastfeeding, so they figured I would be best suited. I went through a three-day peer counselor training and we also do updates, conferences, etc. I keep up with the latest info. I’m not IBCLC and probably won’t be. What I have learned from my experience and my position is good enough for right now and there are lots of resources I can pull from. I call someone if I need expertise beyond my own. I enjoy it for the most part.

What resources are available to nursing moms and pregnant moms who plan to nurse? A class is held for all pregnant women. They are given general info (especially why breastfeeding is best and how WIC can help) at that class. If a mom is interested, an optional second class is offered in which I counsel her one-on-one.

What is required for a mom to receive a free rental pump? We can issue a pump whether the mom is giving formula or not, but first priority is for moms who deliver prematurely or have twins. It is free because they are on WIC. They don’t pay for the kit either; usually they will have received a kit in the hospital, but if not we provide it. If a mom wants to increase her milk supply but has to use formula, we issue a hospital grade pump if one is available. Sometimes there is a situation where a mom needs a pump but it isn’t available, so they must be put on a waiting list. Medela pedal pumps are also available, but we don’t offer them unless we have to. Moms generally don’t want a pump they have to operate with their feet, but they are sometimes used in desperate situations.

Are follow-up visits required? On the contract, a date is listed for the pump’s return and it’s up to us to check up on the patient and possibly offer an extension.

How long does it take to get a free pump? If someone is available to do the paperwork and a pump is available, it can be received that day.

Are women ever given a single-user purchase pump? Yes. Mothers returning to work and planning to nurse for a significant amount of time can get these. The moms are screened, and if they qualify, they get the pump. If they are giving formula, they do not qualify. The baby should be about four weeks old so that the mom will have two weeks to prepare with the pump before she returns to work at six weeks postpartum. These are expensive pumps, so we are careful about giving them out. We give the Medela Swing pump and the Pump in Style.

Is there any other incentive offered to encourage women to choose breast over bottle? Through WIC, an exclusively breastfeeding mom gets more food. Specifically, she gets peanut butter and beans every month rather than every other month. Come May, if not sooner, mothers exclusively breastfeeding will receive $8 worth of vouchers for fresh fruits and veggies.

What benefits are given to moms who bottlefeed? Formula, but not all the formula they need. It’s supplemental, and ends up being about 75% of what the baby needs. In the beginning it is probably enough, but in the end they will probably have to buy some. A mom is on WIC six months if she’s not breastfeeding, but she gets much less food than a breastfeeding mom. She doesn’t get beans and peanut butter like the breastfeeding mom and gets less milk and less juice. She also won’t get fruit and veggie vouchers, or won’t get as much. The aim of WIC was originally to provide supplemental food for babies. Since parents were diluting the formula or offering solids too soon, they changed the program (to offer more) so they wouldn’t do that. It helped with the diluting, but parents were still offering solids too early. Then education came into play and finally they began to educate and encourage the breastfeeding mother. They have nutrition classes for moms who are under or overweight or for babies with failure to thrive.

Do you notice that moms of a certain age seem more likely to choose breastfeeding? Yes. There’s been an increase in teens who will at least try, and also the older moms. Women who are in college are also more likely to breastfeed; education plays an important role.

How do you think South Carolina compares to other states in supporting low-income nursing moms? Not so good. We seem to have a breakdown at the top. In some other states they are allowed to speak more negatively about artificial baby milk, and in South Carolina we’re not. We also need more peer counselor support. Studies show that the more help is available, the more successful the breastfeeding program is. As far as a pumping program, ours may be better. We changed our pump policies because of a study in Illinois in which they found giving out pumps increased the rate of breastfeeding. Before, women couldn’t get free pumps at all except for manual ones.

What do you consider the most important part of your job when it comes to helping women decide to breastfeed and continue for as long as possible? Being available to encourage.

What do you think is the greatest obstacle facing low-income women who want to breastfeed? Lack of support, especially from family and peers. I had a class today, and surprisingly, the women knew breastfeeding was best for the baby, but they chose formula. One was scared, and the other two didn’t feel like they could do it. There’s no encouragement there within the family. Nobody’s doing it that they’re exposed to except us “professionals.”

What is the most frustrating thing about your job? Trying to keep moms encouraged, especially when the doctor is giving information that is contrary to what I am saying. For instance, a mother is not making enough milk and the physician tells her she needs to supplement, but when you talk to the mother she was only nursing a newborn 4-5 times a day and she needs to be nursing more often. She’s in a dilemma: do I trust my doctor or this lady? There are some doctors who tell a mother her milk isn’t good enough because her baby is nursing every two hours. In reality, many babies need to nurse that often. We tell the mother it’s normal, but her doctor has said her milk isn’t sufficient and it’d be best if she would quit. That happens a LOT. It’s an uphill battle sometimes. If we can get them educated prior to delivery, the more educated they are the more successful they will be. Mostly, they need to know what’s to be expected from a baby who breastfeeds because breastfed babies are different from those who bottlefeed.

What do you like best about your job? Meeting the different moms and babies.

What breastfeeding misconception do you run into most often? “I don’t think I’ll be able to do it, because I don’t think I’ll make enough milk.” They just do not believe in themselves. They have a self-esteem problem. They don’t know it, but they do. They can be so adamant and seem so confident about using formula, but when you question them about it, they are really concerned about not being adequate enough for their babies.

Do you see a difference in breastfeeding rates between married and unwed mothers? The ones that are married do tend to do it more, or are more likely to try, because of the support that’s there.

Assuming they are already determined to breastfeed, what can low-income women do to preserve their nursing relationships? They need to ask questions and not give up as soon as a problem occurs. They need to ask for the help that’s available to them. The ones that ask the most questions and bug me the most usually stick with it the longest. Believe it or not, there aren’t that many. Most women are shy, or embarrassed. The mother needs determination.

Why would someone want to avoid the latch (and exclusively pump)? Because of the association of the breast with sex. Some mothers think they’ll feel funny.

Be sure to read the other articles about breastfeeding and poverty at these blogs:

Motherwear's Breastfeeding Blog
Breastfeeding Mums
Breastfeeding 1-2-3
Mama Knows Breast


Anonymous said...

Awesome interview! I am just checking in real fast. I will have a lot to read when I am back from vacation. :)

Take Care!


Sinead at Breastfeeding Mums said...

What a fabulous and extremely interesting post. I agree whole-heartedly about introducing education in schools as a means of getting young people to think about breastfeeding. If only that idea was actually adopted we'd have a much healthier and better educated population of young mothers and fathers...

becka said...

Seriously, this country needs to do MORE MORE MORE to promote breastfeeding. We also need to have more help from the government for breastfeeding like they help pay for formula

Theresa said...

All that being said, I'm still stuck on the part where you asked why no one had told the mom about the feeding while on your side. Yikes, does someone really have to tell them?? We both know that nursing is probably the easiest way to go, especially at night! I LOVED it!!! It was just the natural thing to do. Or at least I thought it was!
Great job on this post, loved it!

Theresa said...

No baby yet - all in good time. She has a dr. appt. tomorrow, so we'll see.
I loved your mom's blog on vinegar - how handy. I just started making my own laundry detergent, and using vinegar as the softener/rinse agent. So far it's great.AND - I'm using vinegar in the rinse cycle of the dishwasher. I'm going to make up some homemade dishwasher detergent soon. I love being simple - ha-ha!
Oh, and I always put the girls in bed with me, and Katy and Heath do too. Much easier and comforting on everyone! don't fix it if it ain't broken!

Sharon said...

You have a very interesting post. I think the problem of getting more moms in poverty in the U.S. to breastfeed doesn't lie solely with "changing the healthcare industry".These mom's have to want to breastfeed their babies and it takes a commitment. Many of the women living in poverty have not had an example to follow of someone "commited to accomplishing something" in their lives. I agree also with Kim that they do not have enough self esteem. Because these Mom's have never been encouraged or told they "can do anything they set their mind to do." They do not have the support of families or friends and breastfeeding is "foreign" to them in their circle of community. Many of these young girls can not invision themselves touching their breasts or having their baby nurse on them, so they choose to "pump".(I have a hard time with their thinking; it creates MUCH more work to pump only, but have not been able to make them realize that). I am an R.N. and a Certified Breastfeeding Counselor. I work for a program that services low income women from pregnancy until their baby turns 2 yrs. old (in PA.)I agree more funds need to be spent on breastfeeding education. In our area, it depends on who your pediatrician is, as to how much you are encouraged to breastfeed. Our WIC offices do support breastfeeding. Many of our clients are in a "poverty survival mode". They have bigger problems to deal with; like where will I be living in a few weeks when I have no rent money? Unfortunately,free formula from WIC is easier for them to deal with than the frustrations of beginning to breastfeed a newborn; even if they are encouraged in the hospital or at home (by me) that it will get easier.

Anonymous said...

Yes Theresa, some one does need to tell them about breastfeeding on their side. Not everyone is familiar with bresatfeeding; the technique nor the benefits. I'm a low-income mother only because I need the state benefits while I am attending college. Contrary to what you may think, not all low-income women are clueless or stupid. Some simply don't have any other choice. I breastfeed both my girls until they were two and recieved numerous comments from total strangers about it. I did what was best for me and my children and here people think they have the right to comment about you feeding your child the best they can possibly get, while they have children that are sucking on pacifiers at the age of 3 and 4. Why doesn't someone tell them that they are ruining their children's teeth? Everything is a learned reaction, the difference is, where are you learning it from?