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Teaching physicians to support breastfeeding by Heather Woolwine Public Relations New and veteran mothers often exchange birthing stories. These same mothers have breast feeding stories, too, which are as varied as the women who tell them. One thing most of these women will have in common is that any discussion of the subject with their obstetricians generally was in passing. Most received a mixed message that did little to support or encourage a mother to nurse her child.   Carol Wagner, M.D., neonatologist and MUSC’s breastfeeding medicine expert, blames a lack of training for physicians during residency, not only about the benefits and research that support breast feeding children, but also how to talk about breast feeding with a patient, for low breastfeeding initiation and retention rates in new mothers.   Dr. Shilpa Shah, a participant in the breastfeeding curriculum for residents, discusses techniques with patient Natalicia Costa. To test this theory, MUSC and six other sites around the country, including UCLA, Johns Hopkins and Duke, will study what impact a breastfeeding medicine curriculum for residents might have on initiation and retention rates for mothers and their babies. The Breast Feeding Promotion in Physicians’ Office Practices is a three-year grant funded through the Maternal & Child Health Bureau and was developed by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. Overall, 70 sites throughout the world are participating in this translational research study headed by principal investigator Lori Feldman Winters, M.D., of Robert Wood Johnson University in Brunswick, N.J.   Wagner serves as the MUSC site coordinator, and recent University of New Mexico School of Medicine graduate Allie Chambers, M.D., serves as the study coordinator. Currently, more than 50 pediatric, family medicine and OB/GYN residents are enrolled in the program that will conclude in June 2007. Wagner and Chambers will look closely at breastfeeding initiation and continuation rates before and after residents started the curriculum.   When Wagner first came to MUSC in 1992, breastfeeding initiation rates were only 19 percent for level 1 babies (normal birth). Today, that rate is 63 percent. For babies in the neonatal intensive care unit, it was 25 percent. That unit now sees an initiation rate of 80 percent. “At MUSC, we do pretty well and a lot of that credit goes to the great lactation team that we have,” Wagner said. Wagner and Chambers’ ultimate goal is to reach 100 percent for all MUSC nurseries.   “This is really a prototype for what will hopefully become a standing training program for residency curricula around the country,” Wagner said. “It was a real honor to be selected to participate. A physician sees a pregnant woman between eight and 14 times during her pregnancy. That leaves plenty of time to discuss the medical benefits of breastfeeding and why it is the best choice for babies and their mothers.”   The program includes presentations given to the residents, reading materials, an online breastfeeding education course and resident participation in small group activities, such as a lactation support group. The curriculum is designed to teach residents the health benefits of breastfeeding, the skills needed to successfully assist mom and baby in breastfeeding, the knowledge to help with common breastfeeding problems, as well as how to get involved in breastfeeding advocacy and how to address pertinent cultural issues related to breastfeeding. Residents will also work with MUSC’s lactation consultants.   “It’s one thing to know the value of breastfeeding and another to encourage it,” Chambers said. “It’s not enough to simply explain the research that supports breastfeeding. We’re hoping to get residents excited about the many benefits of breastfeeding so that they will in turn inspire their patients to overcome any barriers they may have to breastfeeding their child. Physicians have a responsibility to create an environment that is supportive to breastfeeding so that new mothers have a chance of making it the AAP’s [American Academy of Pediatrics] recommended target age of breastfeeding for at least one year, with the first six months being exclusive breastfeeding.”   Abundant studies have documented the numerous benefits of human milk for an infant, including reduced risk of adult and childhood cancers and autoimmune diseases.     Wagner said that the program aims to give physicians the tools to become efficient breastfeeding medicine experts who can confidently and compassionately state the case for providing a baby’s nutrition via nature’s way.   “A lot of trust develops between the OB [obstetrician] and a patient during the course of a pregnancy and through this trust physicians have an opportunity to not only offer evidence that supports the benefits of breastfeeding, but reiterate what a natural, normal part of life it is,” she said. “We inform mothers about all of the developmental milestones their children go through during and after pregnancy, and talking about breastfeeding should be as natural as that.”   Wagner and Chambers also see this kind of training program as a chance to take some of the pressure and stereotypes off of lactation consultants. “Unfortunately, sometimes our lactation consultants are the first ones to ever talk with a woman about breastfeeding. If a woman’s OB or family practitioner has been talking about breastfeeding all along, then when she gets to the hospital to have the baby, she’ll be much more comfortable with and confident about the whole process,” Chambers said. “As a result, the lactation consultants will be free to help with technique, answer questions and problem solve when needed. It’s not their job to encourage mothers to breastfeed. This is a decision a mother needs to make for herself, preferably before she comes to the hospital to have her baby. We, as physicians, need to support her in this process.” Cultural contest: Breast vs. Formula In addition to a lack of physician training in breastfeeding medicine, other barriers seem to keep American and especially South Carolina mothers from automatically choosing breastfeeding as their child’s nutrition source.   “You can’t expect women to successfully breastfeed without taking into account the cultural context within which breastfeeding is viewed,” Wagner said. “Fifty years ago, a scientific formula was developed that was said to be better and a more reliable  source for an infant’s nutrition. It was big business and with a lot of advertising, women getting into the work force, and the fact that it seemed easier, women jumped on it. It became a status symbol to be able to say that your child was bottle fed with formula. However, since that time, 50 years of research in support of breastfeeding now shows us that formula isn’t better and it isn’t the same. And even more interestingly, now breastfeeding is becoming the status symbol.”   In addition to changing demands on a mother’s time in recent decades, Western cultures, particularly the United States, view the breast as an object of sexual desire, thus casting a confusing shadow across breastfeeding for some individuals.   For example, a man walks into a restaurant and is seated next to a family. Midway through the meal, the young infant begins to cry, and his mother offers him her breast while still at the table. The man at the next table complains to his waiter, labeling the act as inappropriate and maybe even denounces it as indecent exposure. The restaurant is forced to choose between the stated needs of the man and the biological needs of the infant. In some cases, the nursing mother is asked to go to the bathroom, where the stall may be the only place to sit and feed her child. Breastfeeding advocates point out that a toilet stall is an unnatural place for anyone to eat, let alone unsanitary. Why do people find the act of breastfeeding in public places inappropriate when it is natural for a mother to feed her hungry infant?   “In American culture, the breast is a symbol of sexuality and that has hampered the rights of breastfeeding mothers to feed their children anywhere they choose, as they should be able to,” Wagner said. “Of 92 cultures in the world, only 13 of those cultures view breasts as sexual symbols. Part of encouraging breastfeeding and encouraging mothers to give their infants the best possible nutrition available is to change how our culture sees breastfeeding.”   After several well-publicized cases and legislative attention, nursing mothers recently received some support from the South Carolina legislature. S.C. Code of Law Section 20-7-97 states: “A woman may breastfeed her child in any location where the mother and her child are authorized to be. Breastfeeding a child in a location where the mother is authorized to be must not be considered indecent exposure.”   Wagner and Chambers also said that MUSC could further help breastfeeding mothers within its midst by securing space for a lactation room on campus. As of now, breastfeeding moms must find empty offices, exam rooms or call rooms to pump when they come back to work. “All we need is a room with a few electrical outlets and a couple of comfortable chairs and we could make a huge difference for the unknown number of MUSC employees who are trying to pump milk for their babies,” Chambers said. “It takes emotional and physical energy for a mom to maintain her milk supply when she returns to work. If we can’t support her efforts, her chances of continuing to pump will drop. With the known health benefits of breast milk, less breastfeeding means more infant illness and more time off for mom to care for her sick baby.”   And it’s other little things that create big cultural barriers. “We have to help remind maintenance and housekeeping staff that if they walk into a patient’s room and see a mother breastfeeding her child, that he or she doesn’t say, ‘Oh! I’m so sorry,’ and quickly run out. Instead, that person should say ‘Wow, good for you. Would you like some privacy?’” Wagner said. “All hospital staff are part of the health care team. Every person who a new mother meets can influence her breastfeeding experience, so we need to focus on what we can do to support breastfeeding mothers.” Friday, Nov. 24, 2006 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. 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