Breastfeeding Medicine

Physicians blogging about breastfeeding

Establishing the Fourth Trimester

with 21 comments

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.

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

Written by astuebe

January 4, 2013 at 12:45 pm

21 Responses

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  1. Thank you, Alison. As usual, you are single-handedly restoring my belief in the ABM. I hope your peers learn from your incredible combo of evidence-based practice, compassion, and ability to think outside the box.

    I have been working on a variety of advocacy efforts, and one of these is to push for a prenatal breast exam and consultation where OBs or nurses could discuss a woman’s medical history to look out for red flags which may suggest common (and less common) lactation problems. It would only be one short visit and could avoid so many more expensive interventions in the long run, so I hope the insurance companies could be convinced of its efficacy. A woman’s desire to breastfeed could also be discussed and marked on her chart as to avoid potential conflict within baby friendly hospitals – if she has a clear intention to formula feed from the start, this should also be respected and proper bottle feeding protocol should be discussed. There is NO reason that discussing the potential problems with breastfeeding should be detrimental to a woman’s success- on the contrary, having prenatal knowledge of PCOS, hypoplastic breasts, inverted nipples, etc, could ensure that the woman gets more intensive help in the maternity ward, or that advanced preparation could be made for donor milk supplementation if desired. This seems like such a no-brainer to me, and it is very frustrating that the same energy we put into “educating” women on the importance of breastfeeding isn’t put into actually helping them do so.

    Fearless Formula Feeder

    January 4, 2013 at 1:10 pm

  2. That was great!


    January 4, 2013 at 1:39 pm

  3. Very thoughtful response and commentary! Thank you!

    Jan Zelleb

    January 4, 2013 at 2:11 pm

  4. Wonderful and insightful post, Alison. Adequate breastfeeding support in the first month is absolutely critical, and until we can provide that for new moms systematically–ie without the moms needing to ask for it, we can’t expect them all to go home and just “get it” on their own. I posted about this a while back on my own blog ( –nice to see you and I are pushing for the same changes!

    Jennie Bever Babendure

    January 4, 2013 at 3:04 pm

  5. Well said, Alison! So glad the Medical community (and the ABM) has someone as articulate and compassionate as you!

    Shannon Hensley

    January 4, 2013 at 3:31 pm

  6. Excellent piece!


    January 4, 2013 at 4:04 pm

    • I do have to beg to differ with the fearless formula feeder on “intention to breastfeed”. We must move away from allowing our own experiences to infuse what we suggest for other women who may, on the surface have similar circumstances to our own, but underneath have very different emotional responses than our own. I also truly believe that no woman can fully understand the choices she makes in feeding her infant before her baby is born.

      I count among my clientele countless women who were convinced they did not want to breastfeed who happily discovered when their baby was placed naked on their chests that a strong desire arose to do the very thing they thought they didn’t want to do. Just as some of the women who most strongly wanted to breastfeed end up giving up completely because they have a hard time accepting the many shades of gray between exclusively breastfeeding and exclusively formula feeding — there are also women who are completely convinced that they don’t want to breastfeed who end up loving it in spite of them previous convictions and becoming its biggest proponents.

      Research from Paula Meier with low income women who had very low birth weight babies showed conclusively that you can assist women who never wanted to breastfeed to be able to provide their own milk without making them feel the least bit guilty or the least bit coerced. In fact, assisting them with proper support made these women feel empowered. The key is listening carefully, providing appropriate evidence to debunk misconceptions, and coupling that with very pragmatic doable actions that the individual mother can embrace. If she feels like she is supported and praised for what she is doing well, in whatever capacity she can do it, she will feel empowered and enjoy feeding her baby however that is accomplished.

      Yes, screening for risk factors should be integrated into the prenatal exams, but I don’t see the need for this to be a separate activity. For every big red flag risk factor that have created challenges for my clients, however, I have inevitably encountered a woman with the same risk factor who manages to breastfeed exclusively with no problem whatsoever. The better obstetricians in my area do this as part of their routine exams and usually do an excellent job of prepping women about how to address potential problems without scaring them.


      January 4, 2013 at 4:43 pm

      • Susan, I didn’t mean to imply that if a woman expressed intention to formula feed that she should be forbidden to have skin-to-skin. That’s something everyone can enjoy, regardless of feeding method, and there’s nothing to say that once a baby does the breast crawl and latches then that mother will have a change of heart. I’ve talked to many women who’ve had that exact experience, so I agree with you that we simply can’t read the future. Unfortunately, I’ve also spoken with women who have been harassed in baby-friendly hospitals despite clearly stating that they did not want to breastfeed. My own sister-in-law had a nurse in her BFHI-adopting hospital force her baby onto her breast despite her very vocally expressing that while she obviously wanted to do skin to skin, she wasn’t intending on breastfeeding and would appreciate the nurse getting her hands off her breasts. Stories like this are what inspired my original comment on breastfeeding intention. I just meant that it could help care providers gauge how hard to push.

        Fearless Formula Feeder

        January 6, 2013 at 6:41 pm

  7. Clapping and kudos! This says an awful lot, and I absolutely agree: “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.”

    I think most moms find all the compassionate and effective support they need from WIC peer counselors, mother-to-mother counselors (like La Leche League) and — in a more perfect world — from a large circle of female friends, relatives and neighbors, all of whom happily breastfed.

    When issues morph from mothering questions to healthcare concerns, then the mother needs access to skilled care in breastfeeding and human lactation: from an International Board Certified Lactation Consultant (an allied healthcare provider) or — if mom is fortunate — from a primary health care provider (a pediatrician, obstetrician or midwife) who **does** have the extra education and training that Selvin’s article laments the lack of.


    January 4, 2013 at 6:13 pm

  8. […] via Establishing the Fourth Trimester « Breastfeeding Medicine. […]

  9. Thanks, Alison! When I read the original article, my initial thought was, “How can I share this with my medical community, to get them to take a more active role in prenatal breastfeeding preparation and post-discharge breastfeeding management?” How can we leverage the capacity of the ACA to get *prenatal education* really provided through insurance plans (if the plan won’t cover the service in the first place, then it doesn’t matter if mom can get it without a co-pay). I notice that ABM does NOT have a protocol concering prenatal education/care, and I wonder how assiduously OBs are utilizing the protocol/outline provided in the Gold Book (Table 5.2, p.60-61), whether the counseling is provided by the OB, ARNP, IBCLC, etc. This is critically important to hospitals working toward Baby-Friendly status, since mothers have to be able to verbalize breastfeeding-related information they received through prenatal services. A protocol that could be used as a basis for payments would be VERY HELPFUL in continuing to strengthen MD practice and mothers’ decision-making processes.

    Doraine Bailey, Lexington-Fayette Co. (KY) Health Dept.

    January 7, 2013 at 9:10 am

  10. Great points — ABM does ihave a prenatal guideline:

    Click to access Protocol%2019%20-%20Breastfeeding%20Promotion%20in%20the%20Prenatal%20Setting.pdf

    I think prenatal support and education are critical — and it’s particularly important to find ways to weave prenatal education into existing pregnancy care. I’ve done some work with Karen Bonuck on two trials she conducted in New York City looking at an integrated pre- and post-natal intervention. The project is described in this paper:

    One of the key challenges in the prenatal period is finding ways to interject breastfeeding education among the long list of items that are covered during prenatal care. Traditional prenatal care, with multiple one-on-one 15-minute encounters, is a pretty inefficient way to teach health behaviors, and models such as Centering Pregnancy may work better for breastfeeding support. We also need to study who is most effective doing what in prenatal education. There’s evidence that patients value their physician’s advice about breastfeeding, but it’s not clear whether we would get the most “bang for our buck” out of 10 minutes of an OB recommending breastfeeding vs. 45 minutes with a peer counselor — or some combination of the two. That’s why it’s critical, as we explore opportunities with the new ACA coverage for breastfeeding counseling, for us to collect data on outcomes so that we can figure out what works best and disseminate those best practices.


    January 7, 2013 at 2:43 pm

  11. Thanks! I apologize for not seeing the ABM protocol — I DID look before typing but apparently didn’t look good enough! Cochrane published a review on antenatal breastfeeding education in 2012 (Lumbiganon et al.) that would be a good document to study for those considering further research, as there appears to have been a lot of work done but little that is replicated.

    Doraine Bailey, Lexington-Fayette Co. (KY) Health Dept.

    January 7, 2013 at 2:50 pm

  12. I totally agree with everything you said Dr. Stuebe! Thank you for bringing this topic to life!

    Susan Patcha

    January 8, 2013 at 11:44 am

  13. Oh this post really got me fired up. I can’t agree more and this is an issue dear to my heart as many of my son and I’s early breastfeeding difficulties could have been avoided if only someone cared to follow up with us. Instead we spiraled out of control into what I remember as hell.


    January 27, 2013 at 4:33 pm

  14. Yes! Thank you! I simply do not have more than a couple milk ducts. I tired everything for months and then went through testing. It was hell. I felt like a failure. I felt like less of a mother every time I pulled out a bottle in front of others. I cried at home when I bottlefed. I simpily cannot breastfeed. And all the while lactation consultants told me I wasnt giving it my all when pumping and nursing was all I did all day and every two hours at night for months. But I just wasnt trying hard enough. Bah! Thank you.


    February 13, 2013 at 1:16 pm

  15. This piece is beautiful but very idealistic. In a perfect work where people truly cared and loved and nurtured each other this could happen. But we live in a world of ego and I know better than anyone how very unhelpful some midwives and especially the australian breast feeding association can be, the two ABA consultants I had I am convinced kick started my post natal depression. The first told me that feeding your child formula was like feeding them McDonald’s and would cause everything from behavioural, iq and learning problems in the future while she went on and on about how she breastfed all her children, how great they were and how she abhors mothers who say they cant and the second shouted at me for half an hour because my son wouldn’t latch on and stay latched on. I am not the only person who has had these kinds of issues with either midwives, dr’s or the ABA. This was when I realised that women need to take a step back out of other mothers lives and offer support full stop. Not just to breastfeed but support even for when they don’t. The whole question of breast feeding need not be asked anymore. Maybe if women felt secure in hospitals and in a society where the main question isn’t “are you breast feeding” but “how are you coping?” The world of being a new mother would be more stress free, more guilt free and boost a mothers self-confidence to a point where she feels persistent to keep going not because she knows she is being judged, not because its whats expected of her but because she’s been given the emotional freedom to think of her child’s well being for once without every other mother and professional thrusting their opinions and expectations between them. If this was to change I’m certain you would see many more breast feeding mothers.


    February 13, 2013 at 4:09 pm

  16. […] has been true throughout human history. The statement, “All women can breastfeed,” is false. It is also harmful, because it implies that women who are not able to breastfeed are not […]

  17. […] has been true throughout human history. The statement, “All women can breastfeed,” is false. It is also harmful, because it implies that women who are not able to breastfeed are not […]

  18. […] families return home, the Booby Traps continue. We serve mothers poorly in the fourth trimester: For most families, postpartum care happens in silos. A pediatric provider cares for the newborn, […]

  19. […] since there have been women, breasts and babies. If only 1% of US mothers had a physiological barrier to breastfeeding (a low estimate), then 30,000 mothers a year would need some other way to feed their babies, at […]

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