For various reasons, I spent 5 days in the hospital recovering from the birth of my first child, who is now 8. He was then much as he is now: precocious, bright-eyed, and nearly always hungry. He took to nursing like he was born to do it (which, of course, he was), and I was proud and happy that he latched within minutes of being born.
But after 21 hours of natural labor followed by an urgent C-section, I was already exhausted by the time he arrived. And soon I felt like my body literally couldn’t keep up with my child. The euphoria I felt as a new mom quickly eroded after 3 sleepless nights of painfully climbing in and out of my hospital bed every few minutes to nurse. Breastfeeding was painful, and as my ravenous child began to exact a fairly severe toll on my body, even the in-house lactation consultant couldn’t help but stare with barely concealed horror at the corporeal damage I was sustaining. Despite having had every intention to breastfeed for at least 1 year, I soon began to question whether this whole breastfeeding thing was going to work.
Eventually, with the help of the lactation consultant, various creams, and a little supplemental formula, my son and I hit our stride around day 10. I was lucky enough to be able to nurse each of my sons for over a year, and I am grateful for having been able to reach my personal breastfeeding goal. But as a recent survey of US physician mothers demonstrated, only 28% of my fellow doctor moms can say the same.
Breastfeeding in America
August is National Breastfeeding Month. Breastfeeding offers many short- and long-term health benefits for both mother and child in addition to the bonding that can occur while nursing. It’s associated with lower incidences of breast cancer and diabetes in moms and lower rates of ear infections and obesity as well as higher IQs in babies. Interestingly, some of the benefits ascribed to breastfeeding are difficult to disentangle from the demographics of who tends to breastfeed in this country. Breastfeeding theoretically provides a free, handy, and imminently portable source of food for infants. But in the US, women who breastfeed are disproportionately socioeconomically advantaged, well-educated, and married. Because the children of breastfeeding mothers often already have a leg up on life in many ways, it’s not always clear whether the good outcomes seen in these kids are due to the privileged circumstances into which they’re born or because of the breastmilk they consume.
Even when we account for these biases, however, the benefits of breastfeeding are sufficiently numerous that exclusive breastfeeding for the first 6 months of life and continued breastfeeding as part of an expanded diet for at least 2 years are strongly recommended by the World Health Organization (WHO). This is especially true for women with limited financial resources, as well as women who live in areas with potentially unsafe water (e.g., Flint, Michigan) or who lack access to refrigeration for making and storing formula (e.g., after natural disasters).
Among US women, we also see significant racial and ethnic differences in rates of both breastfeeding initiation and maintenance. Thanks to various local and national public health initiatives, rates of breastfeeding have increased among African American women, but it is estimated that only 74% of black women in the US initiate breastfeeding, and only about 49% continue nursing until 6 months. In contrast, 88% of Asian-American women initiate breastfeeding (with 72% still breastfeeding at 6 months), 87% of non-Hispanic white women initiate breastfeeding (with 62% still breastfeeding at 6 months), and 83% of Hispanic mothers initiate breastfeeding (with 52% continuing to do so at 6 months).
As physicians, we are taught the benefits of breastfeeding as part of our training and are encouraged to promote the ethos behind the WHO’s recommendation that “breast is best.” But in this regard, especially in America, we physicians are often failing to practice what we preach.
Why Doctors Don’t Breastfeed
Dr. Katrina Mitchell (a breast surgeon and lactation consultant), Dr. Rebecca Snyder (a surgical oncologist at East Carolina University [ECU]), and Dr. Helen Johnson (a surgical resident at ECU), recently published a call to action in the Journal of Graduate Medical Education. In their paper, they expand upon the results of the survey of 2,363 US physician mothers I referenced earlier:
- Almost half of respondents would have liked to have breastfed for a longer period of time if their jobs had been more accommodating.
- Junior faculty (those <4 years in practice) and physicians in procedural specialties such as general surgery were less likely to breastfeed for at least 12 months.
- After adjusting for other covariates, women with longer maternity leaves, dedicated space to pump, and more flexible schedules were more likely to report reaching breastfeeding milestones.
For residents, the challenges of breastfeeding are especially stark. Compared with their faculty counterparts, physicians-in-training generally have shorter maternity leaves (typically 4 weeks or less, and usually consuming ALL of their vacation for the year), have less time and flexibility during the work day to express milk, and are less likely to have a clean, private space (such as a personal office or lactation room) in which to pump. They may also hold back from asking supervising physicians for time to pump for fear of being perceived as less committed to patient care than their colleagues. Unsurprisingly, a recent study of 347 female surgeons who were pregnant during their general surgery residencies revealed that although breastfeeding was considered important by over 95% of respondents, more than half (58.1%) stopped breastfeeding sooner than they wished due to poor access to lactation facilities and challenges arising from leaving the operating room to pump.
In their paper, Helen, Katrina, and Rebecca advocate for a universal, pro-breastfeeding policy that would be implemented at every US training program. They provide itemized goals and action steps that would allow residencies to actively support lactating resident physicians via cultural and logistical reforms. In 2018, the Accreditation Council for Graduate Medical Education did revise the Common Program Requirements to include language that encouraged residencies to be generally supportive of breastfeeding residents, but few institutions have translated these suggestions into policies. A notable exception is the Department of Surgery at the University of Michigan, where faculty and residents have worked together to develop a departmental policy that supports lactating residentsand is rooted in a commitment to fostering an inclusive and diverse workforce.
Thus, even though physicians (even as residents) are inarguably among the most privileged members of American society, breastfeeding promotion and support remains a challenge among us, one that is only gradually changing as the demographics, priorities, and leadership of the medical community evolve.
So if breastfeeding is hard for those of us with a surplus of resources and the privilege of job security, what is it like for those who have neither?
How We Fail Mothers and Their Babies
During one of those first few nights in the hospital with my son, I used one of his rare naps to wander over to the newborn nursery to get an extra burp cloth. I had delivered at the same urban, tertiary-care center where I was also a resident, and it felt a little eerie being a patient on the same floors where I had staffed consults and even coded patients. My son was “rooming in” with me, which is an evidence-based strategy to encourage bonding and promote on-demand breastfeeding. So when I walked into the newborn nursery and saw row after row of babies, I was perplexed. I asked one of the nurses why there were so many babies here. Was I the only mother on the floor engaged in this misguided pursuit of mother-child bonding at the cost of my sanity?
The nurse paused and smiled. She explained that for many of the moms who were my neighbors on the postpartum unit, this time in the hospital after delivering a baby was an opportunity to rest before diving back into their lives, now with a new baby in tow. Indeed, it might be their only time to rest before they had their next baby, which might be quite soon.
I pondered this response as I walked gingerly back to my room. Here I was desperately trying to make breastfeeding work, and all at once I was overwhelmed by just how lucky I was. Lucky enough to be able to time my pregnancy so that I could deliver during the research years of my surgical residency. Lucky enough to have Duke Medicine alum Dr. Mary Klingensmith (Class of 1992), a visionary leader in surgical education, as my residency program director at Washington University in St. Louis, and for her to insist that I take a more generous maternity leave than I had originally intended. Lucky enough to have private, clean lactation facilities available to me when I was working as a lab resident. Lucky enough to have the hospital-based daycare center my son would attend just a short walk from my office, so I could stop by to breastfeed him during the day. And when I got home, I was lucky enough to have a wonderful partner who would wash all the bottle and pump parts and carefully transfer the milk I had expressed to bottles for our son to take to daycare, or for my husband to feed him with at night when I needed a break.
As hard as it was for me to get breastfeeding going, I knew what the future could hold if I could just get there. But for my postpartum neighbors, many of whom faced job insecurity, tenuous child care, and varying levels of domestic support when they and their babies were wheeled out of the hospital, the systemic barriers to breastfeeding that loomed may very well have felt insurmountable. As my lactation consultant sunnily reported to me a couple of days after my son was born: “It’s natural, but it’s not intuitive!” As if knowing that women and other mammals had been breastfeeding for millennia would make me feel better about my own current struggles. As if the postpartum body’s ability to fully sustain another human being could feel that miraculous if it never gets a fighting chance to do so.
Using Evidence to Enable the Practice and Demonstrate the Value of Breastfeeding
The Carolina Global Breastfeeding Institute (CGBI) was founded in 2006 at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill (UNC). It is the first ever public health institute devoted to promoting the “3 B’s” – Birth, Breastfeeding, and Birth Spacing – as part of a holistic, intergenerational approach that enables women to breastfeed via community engagement, education, and research.
In 2018, CGBI launched ENRICH Carolinas, a program that provides technical assistance and training for birthing centers, hospitals, childcare facilities, and prenatal clinics on how to transform themselves into lactation-friendly sites that support breastfeeding both in the hospital and after delivery. Originally piloted in 19 NC counties, the program has now received funding from The Duke Endowment (no relation to Duke University) that will allow it to be expanded to ALL hospitals providing maternity care in North and South Carolina at no cost to the facilities.
But innovations at CGBI go beyond public health initiatives and even extend into the realm of developing technology that provides logistical and physical assistance to nursing moms. Dr. Kristin Tully, who has a PhD in biological anthropology, is a research associate at the UNC Gillings School and a member of CGBI. Kristin leads an interdisciplinary team of researchers from UNC and North Carolina State University that has developed a potential game-changer for moms like me who struggled to get in and out of bed after a surgically assisted delivery. The Couplet Care Bassinet™ is designed to allow moms easy access to their babies when they room-in and does not require them to get out of bed to pick up their babies. It also prevents tired postoperative moms from resorting to keeping their babies in bed with them, which can be dangerous. Thus, through both population-level and patient-level innovations, CGBI is working to address modifiable barriers to breastfeeding initiation and maintenance.
However, it’s important to recognize that even with maximal support, breastfeeding can be difficult or even impossible for some women. Duke alumna Dr. Alison Stuebe, a collaborator of Kristin’s, is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at UNC, a distinguished scholar in infant and young child feeding, and a faculty member at CGBI. She is also the vice president of the Academy of Breastfeeding Medicine.
“The breast is not infallible,” she explains, “and there are women for whom breastfeeding is not possible. But we don’t have great solutions for women who want to breastfeed but have difficulty, and there is a lack of knowledge about how to provide physiologic support to these women.”
Alison is, of course, a strong advocate for breastfeeding, but she emphasizes the importance of women’s not only having the ability to breastfeed but also the right to do so.
“If we recommend breastfeeding to a woman who has to go back to work at 10 days postpartum, breastfeeding is not a choice. It’s a privilege. And we also have a ridiculous situation in this country where 23% of moms working outside the home are back at work by 10 days postpartum. We need to think of the socioecological circumstances that allow women to make and execute a free and informed choice as to how to feed their babies. Furthermore, not only is there a lack of knowledge, but there is also poor diffusion of knowledge among healthcare providers because we don’t teach breastfeeding as part of normal physiology within medical school.”
At the same time, Alison emphasizes the importance of empowering a woman’s choice to decide what is best for her own needs and those of her child.
“Ultimately, each woman is uniquely qualified to determine what is optimal for her and her baby given her life circumstances, whether that is exclusive breastfeeding, mixed feeding, or exclusive formula feeding.”
CGBI’s multipronged approach to promoting breastfeeding also includes assessments of what we collectively lose when breastfeeding rates are suboptimal. Alison was the senior author on a project that used a Monte Carlo simulation to estimate the excess costs and cases of pediatric and maternal morbidity and mortality that could be attributed to suboptimal breastfeeding rates in the US. She and her co-authors reviewed the literature to select 5 maternal conditions (breast cancer, diabetes, hypertension, myocardial infarction, and pre‐menopausal ovarian cancer) and 9 pediatric conditions (acute lymphoblastic leukemia [ALL], acute otitis media, Crohn’s disease, ulcerative colitis, gastrointestinal infection, lower respiratory tract infection requiring hospitalization, obesity, necrotizing enterocolitis, and sudden infant distress syndrome [SIDS]) with established associations with breastfeeding.
“The breast is not infallible, and there are women for whom breastfeeding is not possible. But we don’t have great solutions for women who want to breastfeed but have difficulty, and there is a lack of knowledge about how to provide physiologic support to these women.” – Dr. Alison Steube
Outcomes for these diseases and their associated costs were modeled for both a cohort of US women who were 15 years old in 2002 and for the children they would be expected to bear over their lifetimes using 2012 population fertility rates. This cohort of women and children was divided into two arms: a “suboptimal arm” with breastfeeding rates equal to 2012 levels, and an “optimal arm” with 90% of infants breastfed in accordance with the medical recommendations of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (6 months of exclusive breastfeeding and up to 1 year of breastfeeding as part of an expanded diet). Costs for each disease were derived from Medicare fee schedules and/or published data and were divided into direct medical, indirect medical, indirect non-medical, and premature (i.e., before age 70) death costs. A simulation of 10,000 replications with 100,000 women per replication was performed.
In the simulation, an estimated 1,994,000 women gave birth to 3.75 million infants. There were fewer deaths with optimal breastfeeding for all conditions except ovarian cancer in the mothers and ALL in the infants, with maternal deaths representing 78% of all excess deaths. Costs (in 2014 dollars) were lower with optimal breastfeeding for all conditions except ovarian cancer, with suboptimal breastfeeding accounting for more than a $3 billion excess in direct medical costs and more than $14 billion in excess costs due to premature death. Notably, 1 maternal or pediatric death was prevented for every 597 women who pursued optimal breastfeeding (i.e., the number needed to treat). The team has also created an online calculator where you can quantify the impact of suboptimal breastfeeding by US state.
Thus, policies designed to enable breastfeeding have huge implications for the health of moms, their babies, and the healthcare system. But commitments by employers and professional societies will not be enough to equip women with the temporal, spatial, and cultural resources to enable sustained breastfeeding. Instead, policies that support breastfeeding will also need to be implemented at the federal and state levels as well.
Liquid Gold: A Resource that Should Be Available to All
Among nursing moms, breastmilk is often referred to as “liquid gold.” In my hormonal postpartum state, few things made me cry as much as spilling the hard earned breastmilk it had taken me 30 uncomfortable minutes to pump. But as with so many other resources, the opportunity to provide and receive breastmilk has become a case of the rich getting richer. Thanks to the efforts of Alison, Katrina, Kristin, and others devoted to helping women successfully breastfeed, I hope that we can collectively work to get liquid gold into the mouths and bellies of as many babies as possible and to make breastmilk the universal resource it’s meant to be.