Establishing the Fourth Trimester
Lisa Selvin’s provocative article, “Is the Medical Community Failing Breastfeeding Moms?” has elicited a wide range of reactions from the breastfeeding community. Some have argued that the piece, which focuses on unmet needs of mothers who encounter physiologic problems with breastfeeding, “sensationalizes” breastfeeding, making it sound so treacherous and difficult that mothers should avoid it altogether.
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. One afternoon in my lactation clinic, I saw two consecutive mothers for consults — one pregnant, and one planning pregnancy — who had not been able to make milk for their babies. Each woman told me, “I had no idea this could happen. Do you ever see other women with this problem?” I could answer, truthfully, “Yes, in the room next door.”
Even if only one percent of mothers are not able to breastfeed (and that’s a very, very low estimate), with 3 million mothers (75% initiation, 4 million births), that’s 30,000 women a year who are blindsided by problems with a process that is largely promoted as something “every mother can do.”
In obstetrics, prenatal care is designed to detect relatively rare disorders — preeclampsia, gestational diabetes, gestational hypertension — and we counsel mothers to monitor fetal movement, loss of fluid, contractions and bleeding to identify pregnancies at risk. It’s debatable how well we succeed in improving outcomes vs. medicalize a normal process. But there is precedent for honoring normal physiology without turning a blind eye to unexpected problems.
It’s largely because of the risk of preeclampsia and gestational hypertension that I see mothers once a week, starting at 36 weeks of pregnancy. These visits are brief, essentially to check their blood pressure, ask if the baby is moving, and talk about what to expect in labor. There’s a case to be made that lactating mother-infant dyads need at least as much support in the first month of life as gestating women need in the final weeks of pregnancy. There’s a lot more conscious decision-making involved in mother-infant interface the first 4 weeks of motherhood — but most women are completely on their own, dependent on well-intentioned family members and friends to navigate plunging hormones, sleep deprivation, and establishing breastfeeding.
We need every health care provider to have a working knowledge of breastfeeding and appreciate that lactation is a normal part of reproductive physiology. We also need those who see mothers and infants to be able to differentiate the normal challenges of breastfeeding from lactation failure, working in concert with International Board Certified Lactation Consultants to ensure comprehensive, timely diagnosis and treatment of problems. And we need research to develop the evidence for Breastfeeding Medicine specialists to address complex breastfeeding problems, just as Maternal Fetal Medicine physicians care for high risk pregnancies.
We also need a system of care that takes the Fourth Trimester as seriously as the preceding three. We need to think carefully and creatively about what level of support will identify moms at risk and triage them to the appropriate level of care, without medicalizing normal breastfeeding. We need to develop and test the “weekly postnatal check” — whether at home, in a Baby Cafe, or in a health center — and, when we know that it works, make it an integral part of reproductive care.
In the meantime, we need to end the silence and judgment directed at mothers for whom breastfeeding does not work. For much of human history, infertility, miscarriage and stillbirth were interpreted as character flaws — barren women were divorced or abandoned, and pregnancy loss was deemed to be punishment for sinful behavior.
That legacy persists today in the innuendo — and outright hostility — directed at mothers who are accosted for bottle-feeding and told that if they really tried — translation: “If they were good mothers and loved their kids” — they would be able to breastfeed. It’s time to put that misogyny behind us, and respond to women who struggled with breastfeeding by simply saying, “I’m so sorry you had to go through that.”
And then, if she’s had a chance to heal from her experience, “How do you think we can help make it easier for other moms?” If we listen — with curiosity and without judgment — we just might find some solutions.
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.
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