Breastfeeding Medicine

Physicians blogging about breastfeeding

Building a breastfeeding culture

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Breastfeeding take a village. For me, the star of the team is my husband, who stayed at home with our baby and brought him to visit on long weekend shifts.

I started my internship in Ob/Gyn the day my first child turned three months old, walking down Brookline Avenue to Brigham and Women’s Hospital with a Pump-in-Style slung on my back and a vague determination to breastfeed. The first day of orientation, I went hunting for the lactation room I’d been told was on the 15th floor of the hospital, only to learn that it had been closed months ago. Some merciful nurses let me into their break room, and I pumped hunched in a corner, contemplating this inauspicious beginning to working motherhood.

After a few days, I found the actual lactation room (on the 9th floor of a different building), and I settled into a routine of blending clinical work with every-three-hour breaks. This was before hands-free pumping bras, and I gradually mastered the art of balancing bottles on my knees while answering pages and reviewing patient charts. By the time I had my first overnight call, I’d learned to pre-assemble my pump parts, screwing the flanges onto the bottles at home and covering them with sandwich bags so I could save a few precious seconds.  That first night, I forgot to pack tops for the bottles, and found myself in the newborn nursery and Mass General, where more merciful nurses borrowed tops from sterile water bottles so I could take my milk home.

Another call shift, after an increasingly excruciating six hours of catching babies and writing progress notes, I staggered into the storage closet / pumping room to discover that I had the wrong pump attachment. The midwife on call came to my rescue, tracking down the right tubing and bringing me a tangy cranberry-juice-and-Shasta-ginger-ale cocktail.

Like every mother who juggles pumping and working, I could go on and on– the pumping in airplane bathrooms on long haul flights, the Fed Ex’ing of 100 ounces of pumped milk on dry ice to my in laws when my husband took our son to visit them, and the sweet, sweet comfort of putting my baby to breast after a 36-hour shift.

Most of all, I am grateful – grateful to a confluence of people and circumstances that made it possible for me to continue breastfeeding through my child’s first year and beyond. Eleven years later, I realize that there was not “one thing” that made it possible – in fact, there were multiple factors that helped me succeed. And if we want to build a breastfeeding culture, we need to build multiple influences into every mother’s experience so that she has the best chance of succeeding.

In fact, there is a tremendous body of social science literature behind this warm-and-fuzzy idea. In their book, Influencer: The Power to Change Anything, Kerry Patterson and co-authors explain that, in order to change behavior, individuals have to answer two questions: “Is it worth it?” and “Can I do it?”  For breastfeeding, then, a mother needs two things: motivation and ability. Moreover, Patterson explains that motivation and ability can be personal, social or structural.  Based on this rubric, Patterson explains, there are six sources of influence:

To change a behavior, an individual needs to answer two questions: “Is it worth it?” and “Can I do it?” Too often, in breastfeeding, we stop with one question, and then wonder why our intervention doesn’t work.

As I read Influencer and contemplated my own experience, I realized that each of these six domains kept me pumping during my intern year. I was personally motivated because breastfeeding became part of my identity as a mom.  Some weeks, I worked 80 to 100 hours – after a particularly brutal call, I fell asleep reading my child “The Very Hungry Caterpillar” – my husband noticed because he heard me mumble, “The next day, the very hungry caterpillar was paged to the emergency room for an ectopic pregnancy…” Yet, every time I sat down to pump, I renewed my connection to my baby. I remember telling my colleagues, “They can take my sleep and my sanity, but they can’t stop me from breastfeeding.”

I also built personal ability – part was dumb luck, in that my milk supply somehow weathered four to six hour intervals between pumping. I also learned early on that my stress level when I sat down to pump was inversely correlated with my milk flow. I learned to take a deep, cleansing breath and close my eyes, and milk would begin to flow more swiftly. With deliberate practice, it got easier and easier.

Social motivation, more commonly known as peer pressure, was critical – one of my chief residents who was pumping for her son was a key role model, and a recent residency graduate gave me life-changing advice just before I started work. She said, “When you tell someone that you need to go pump, you’ll get two kinds of responses: ‘That’s great,’ or ‘Gross, I don’t want to think about it.’ Either way, they will want you out of their site.”  Her words gave me the nerve to tell my attending on my first shift that I needed to go pump – and I was on my way.

The fourth source of influence is social ability – the teams we need to succeed. Front and center is my husband, who stayed at home with our baby, brought him to visit on long weekend shifts, and more than once braved traffic in downtown Boston to bring me some essential pump part before an overnight call.  My co-residents held my pager and had my back when I scampered off to pump between cases or after rounds.  My chief residents, fellows and attendings took it all in stride. And there were the angels that helped me frantically search for missing pump parts in supply rooms, or find an office to borrow during a busy clinic. With apologies to Hillary Clinton, ‘It takes a hospital’ for a resident to breastfeed.

One of the tenets of structural motivation is to celebrate small wins. I counted off the weeks that I brought home breast milk, grateful to have made it through another 7 days.  When I started, I year seemed impossible – so my goal was always to make it to the next week.

Finally, there were supports in the environment — the structural ability —  that made it possible for me to succeed. Both hospitals where I worked had lactation rooms. I lived close by, so my husband could walk our baby to visit if I had a few minutes to spare.  And I worked in Ob/Gyn, where many of my supervisors were mothers themselves, and where birth and breastfeeding are central to what we do.

Would I have sustained my milk supply through a year of residency without all of these supports? It’s possible – but it’s unlikely.  To build a breastfeeding culture, we need to take on all six sources of influence to make success virtually inevitable. In fact, efforts that employ four or more sources of influence are ten times as likely to succeed as those that use fewer than four sources.

For a vivid example, watch Influencer’s video, “All Washed Up,” starring Hyrum Grenny, son of one of the book’s authors:

Source: via Alison on Pinterest



As I learned about the six sources of influence, I realized that breastfeeding campaigns often fall short because they focus on only one source of influence. The NBAC “Babies are Born the Breastfeed” campaign used personal motivation – exclusive breastfeeding for six months reduces ear infections, obesity and asthma – to try to change feeding behavior. Ban the Bags tackles structural ability, changing the environment by removing formula marketing from hospitals.  Prenatal breastfeeding classes may combine motivating information about the health effects of feeding with practical skills, such as how to recognize a good latch and what to expect about infant feeding patterns.

But the authors of Influencer explain that fewer than four domains of influence typically fail to change big problems or ingrained behavior patterns. Translated into breastfeeding, that equals mothers who are Booby-Trapped by underwhelming support to address an overwhelming challenge.

Indeed, I suspect that much of the backlash against breastfeeding derives from well-intentioned, single-influence efforts.  That’s why I’m such a tremendous fan of  Best for Babestm, a brilliant example of multiple-source influence.  Their essay, “What are the Booby Traps?” tackles all six sources of influence.  Browsing their web site, you’ll find plenty of personal motivation and concrete advice, mingled with social motivation from celebrity breastfeeding mothers and calls to action to find strength in numbers, harnessing social ability via advocacy and outreach. Finally, Best for Babes targets structural ability, targeting the Booby Traps that prevent mothers from achieving their infant feeding goals.

The bottom line? We need to integrate multiple sources of influence into all of our efforts to support mothers and babies. Whether we are helping first-time moms to start breastfeeding, working with veteran health care providers to transform their practices, or educating retail managers about how to accommodate nursing mothers, one source of influence is not going to get us there.  There’s a lot of work to do — but there are proven tools to get it done. To get started, visit my Pinterest board, Inspiring Breastfeeding.

So what do you want to change? And how are you planning to start?

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the board of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

November 16, 2012 at 1:28 pm

Posted in Breastfeeding, policy

9 Responses

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  1. What a great blog post, Alison! I can see how this framework would be helpful for breastfeeding advocates to consider, to help broaden our efforts and make them more successful. I plan to share this with other La Leche League Leaders in Nebraska (this would be a great topic for a LLL Leader retreat!) and with my colleagues at I think that MilkWorks is already integrating multiple sources of influence but we can always do more!

    Sara Dodder Furr

    November 16, 2012 at 3:30 pm

  2. I am ever grateful to having had not one, but two, breastfeeding-friendly employers. And one was grateful to his breastfeeding employees — we were very loyal. We were allowed lots of time at work WITH our infants, especially during the early months, and kept travel cribs in our offices. With the exception of one disgruntled employee, co-workers gladly brought and offered food and drink at lunch, and enjoyed having the mood lift and distraction of baby-bouncing on tense days.


    November 17, 2012 at 1:25 pm

  3. […] Building a Breastfeeding Culture, Breastfeeding Medicine — A look at what it takes for mothers to breastfeed successfully.  ”To change a behavior, an individual needs to answer two questions: “Is it worth it?” and “Can I do it?” Too often, in breastfeeding, we stop with one question, and then wonder why our intervention doesn’t work.” […]

    Saturday Surfing

    November 17, 2012 at 10:50 pm

  4. This is a great post. I never would have survived nursing both my children for a year each without an online community of moms I found. They were there as I cried on maternity leave and through five bouts of mastitis. And the support of my husband who believed in what I was doing and picked up the slack at home so I could focus on nursing. And the lactation consultants at our hospital who returned calls on the weekend. And most of all for the labor nurses who helped me successfully fight a hopelessly stupid and out of date neonatologist who claimed my 36-week baby girl was too early to nurse and that I had no milk. I was pumping 3 ounces at a time 24 hours later and went on to nurse her for a year. All because I was confident from having nursed my son and willing to fight for what I wanted. And of course lucky she could suck!
    Thank you for posting this.

    Jacqueline Palfy Klemond

    November 19, 2012 at 9:06 pm

  5. What a wonderful, well-written, thoughtful article. As a midwife, I tell my patients who express concern about their ability to breastfeed that nothing re-connects you more quickly to the child you have been away from than putting them to breast. Any challenges that you faced at work or getting yourself home to be with your wee one just melt away as you sit down and feed your baby. We need supports for this relationship at every turn — home, office, and beyond. Thanks for the amazing article!

    Meg Berreth

    November 19, 2012 at 9:54 pm

  6. […] breastfeeding supporter should read this recent blog post by Dr. Alison Stuebe of Breastfeeding Medicine. In the post, Dr. Stuebe describes a brilliant […]

  7. Hi, I couldn’t find another way to get in touch, so am leaving a comment here. Your blog is great and I hope you’ll get around to posting about reasons for insufficient milk. I produced almost no milk for my now 15-month-old, despite (frequent and long) on-demand feeding + extra pumping, tons of skin to skin, herbs, and finally Reglan. I was never able to pump more than an ounce at a time from both breasts and before and after weighings showed she didn’t get even that much in nursing sessions. I was never able to get an answer about what could be the problem. All of my hormone levels were normal, although I was induced and was on Pitocin for over 24 hours and wondered if that could have had an effect. Would love to see a post about various reasons for uncorrectable low supply (or more ways for correcting low supply!).


    December 16, 2012 at 9:52 pm

  8. What an amazing insight. I will refer to this chart many times, I can already tell. It’s the first I’ve seen of it but it makes so much sense to me. My story is similar, although I was lucky enough to bring my first baby with me to work until he was 10 months old and I quit. In hindsight it makes so much sense how certain things were in place for me to succeed. It also makes me reflect on others mothers decisions to not breastfeed, because of the challenges in their paradigm that can be labeled right into this chart. I also see how this ties into my re lactation journey. On one hand, I feel I had an overwhelming instinct to give my baby my milk, and I had my husbands never ending emotional support. BUT, I did get that little miracle from my son where at five weeks old he randomly latched for the first time. Had he not done that, I can’t say we would be here now and life would fdefinitly not be the same. We are in a new city, new jobs and educations and friends and paths all because of that journey.

    Anyway, I do completely agree with you that breastfeeding support falls short, now looking at this six sources model. I’m very glad I came across this, again I plan to keep this in mind in my own teaching.


    January 23, 2013 at 9:33 pm

  9. […] who have experience breastfeeding and expressing breast milk for their children. Looking back on my first days as an Ob/Gyn intern and mom of a three-month-old, I have a visceral sense of how helpful it would have been to have Dr. Milk as a sounding board and […]

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