How to Enhance Support for Breastfeeding Mothers and Ultimately Improve Maternal Mental Health

Enhancing Support for Breastfeeding MothersThis article originally appeared in 2020 Mom’s ‘Emerging Considerations’.

My story

The first time my son nursed, it was painful, but I was prepared for it. I’d never breastfed an infant before, and I knew there would be a learning curve. What I didn’t expect was to find a bruised, blistered nipple when he unlatched. I remember my midwives looking slightly perplexed, proposing I try a nipple shield. Despite their suggestion, I decided to continue to try to feed him without one. “We’ll get the hang of this,” I thought.

The pain persisted however, and in addition, I found it impossible to keep my son awake long enough to drain each breast. He’d nurse for a minute, fall asleep, and wake again within the hour for more. After three weeks, I was exhausted. Looking for guidance, I dropped into a local breastfeeding support group run by a lactation consultant named Meg. Upon hearing our story, she suggested we meet for an individual evaluation.

Meg arrived at our house the next day. I’ll never forget the punch-in-the-gut feeling that accompanied the words: “It looks like your son hasn’t gained weight since last week.” Until my son was two weeks old, he had steadily gained. By week three, my milk supply had dropped due to our breastfeeding challenges. After performing a comprehensive exam, Meg recommended he be further evaluated for tongue-tie.

Tongue-tie (ankyloglossia) or “tethered oral tissue” is a condition that restricts the tongue’s range of motion. According to the American Academy of Pediatrics (2016), it affects up to 10% of the population. When a baby is “tongue-tied,” unusually tight frenulum tissue tethers the tongue to the floor of the mouth, making it difficult to breastfeed. It can also cause long-term health concerns such as speech problems, difficulty chewing and swallowing, dental decay, and migraines (Fernando, 1998).

Meg referred us to a physician who specialized in treating tongue-tie. As I filled out the patient questionnaire, I found myself ticking all the boxes. Baby’s symptoms: falls asleep while nursing, difficulty latching, gumming or chewing the nipple, poor weight gain, and short sleep episodes. Mother’s symptoms: bruised or blistered nipples, pain when baby latches, incomplete breast drainage, plugged ducts, and mastitis.

It was determined we could benefit from a procedure called a frenotomy, in which a laser or surgical tool is used to cut and release the tethered frenulum. After a challenging few months, the combination of the frenotomy and efforts to boost my milk supply paid off—we are still breastfeeding at 22 months!

Our journey to where we are today was not without it’s emotional challenges, however. I was anxious and sleep-deprived. There were days I didn’t leave the house due to how frequently I had to nurse or pump breast milk, and the pressure mounted until I was utterly exhausted.

During this time, I was incredibly privileged to have access to a breastfeeding support group, in-home lactation consultation, medical supplies such as a hospital grade breast pump and supplemental nursing system, and a local physician who specialized in tongue-tie. Furthermore, my insurance covered a percentage of these costs. This is not the norm. The vast majority of women do not have access to the resources needed to diagnose and treat complications like tongue-tie due to a dearth of support for breastfeeding mothers.

Barriers to breastfeeding support

I recently had the opportunity to discuss these issues and their impact on maternal mental health with Joy Burkhard and Genevieve Colvin, IBCLC. Joy is the founder and director of 2020 Mom, which spearheaded the California Task Force on the Status of Maternal Mental Health Care that issued its report this May. Genevieve is an International Board Certified Lactation Consultant (IBCLC) in the San Fernando Valley and member of the California Task Force. This is what I learned from our dialogue:

  • The Affordable Care Act improved women’s health coverage by requiring most insurance plans to cover breastfeeding support and supplies; however, many insurance companies still don’t cover lactation services outside of hospital settings.
  • Furthermore, most states, including California, do not license International Board Certified Lactation Consultants (IBCLCs). Therefore, IBCLCs have a difficult time contracting with insurance companies to provide reimbursable outpatient services.
  • Due to a significant lack of outpatient lactation services, it is unlikely a mother will receive additional lactation support outside of the hospital unless she is WIC eligible or can pay for the expense out-of-pocket.
  • In the United States, the vast majority of women give birth in hospitals. The 24-48 hour period spent in the hospital after delivery is generally a new mother’s only opportunity to work with a lactation consultant (if one is on staff). During these meetings, which sometimes last just minutes, complications like tongue-tie are screened for only if they are immediately apparent or if a parent insists.
  • If (despite the aforementioned barriers) an IBCLC performs a comprehensive evaluation and determines tethered oral tissue may be negatively impacting breastfeeding, he or she must make appropriate referrals to professionals who can diagnose and treat it. While lactation consultants are trained to recognize breastfeeding complications like tongue-tie, it is not within their defined scope of practice to diagnose them. Instead, they are expected to refer to professionals who can, e.g. physicians and pediatric dentists.
  • Only physicians and pediatric dentists can diagnose and treat tongue-tie, yet they frequently lack the training to provide breastfeeding support or to make appropriate referrals for necessary post-frenotomy therapies.
  • While multiple, empirically validated assessment tools exist, there is no universally agreed upon definition, examination method, or classification system for the diagnosis and treatment of tongue-tie. The American Academy of Breastfeeding Medicine (2004) offers a protocol for the evaluation of tongue-tie, yet many physicians do not use it.
  • Doctors who perform frenotomies are often in high demand, so there can be a wait to see them. While a mother waits to see a specialist, she and her baby continue to struggle.

Why is this important?

There is a positive correlation between breastfeeding difficulties and postpartum depression; meaning, mothers who report breastfeeding difficulties demonstrate higher rates of postpartum depression than their counterparts. In a study published in 2015, Brown, Rance, and Bennet examined the relationship between specific reasons for stopping breastfeeding and postpartum depression symptoms in mothers with infants, ages 0-6 months.

They found that mothers who breastfed for shorter durations, specifically due to physical difficulty and pain, scored higher on a test measuring postnatal depressive symptoms. Moreover, they found negative breastfeeding experience to be predictive of postpartum depression symptoms, specifically when challenges are due to physical difficulties or pain.

The factors influencing the development of postnatal depression in relation to breastfeeding complications are still not fully understood; therefore, further studies are needed to examine this relationship.

How to enhance breastfeeding support

  • Increased support should be directed toward mothers who want to breastfeed but are considering stopping due to physical difficulties or pain (Brown, Rance, & Bennet, 2015). According to Hannula, Kaunonen, and Tarkka (2008), guidance that encourages self-efficacy while empowering new mothers is especially beneficial.
  • Due to the Affordable Care Act, federal law now stipulates that insurance companies must reimburse out-of-network costs if they cannot provide in-network lactation services. Unfortunately however, many insurance companies still refuse to cover services outside of hospital settings (Benyo, 2015). Taking necessary steps to comply with the law and reimburse outpatient services will increase a mother’s chance of receiving breastfeeding support.
  • Hospitals can support new mothers by opening outpatient lactation clinics. These clinics generally offer free, low-cost, or reimbursable services to women who need additional breastfeeding support after leaving the hospital. For example, the Lactation Resource Center at Good Samaritan Hospital in Los Angeles offers consultations with IBCLCs and Certified Lactation Educators (CLEs), support groups, educational classes, and supplies. The center is grant-supported; so all services are free or donation-based and available to any mother in the Los Angeles area regardless of where she delivered.
  • Individual states, such as California, can begin developing rules and regulations to license lactation consultants. Once licensed by the state, IBCLCs can join insurance networks to ensure their services will be reimbursed. Additionally, physicians may be more encouraged to include lactation consultants in their practices if their services are covered by insurance and regulated by the state.
  • Lactation support for mothers who want to breastfeed should be included in prenatal, pediatric, and postpartum checkups. Staffing lactation consultants in outpatient obstetric and pediatric clinics would further increase the likelihood of mothers receiving outpatient breastfeeding support (Farver, 2016).
  • Physicians treating pregnant women and new mothers should be familiar with the complications that can contribute to breastfeeding difficulties. Additionally, if health insurance companies reimburse doctors for time spent attending to breastfeeding issues, they will be more likely to include these services in their practice (Davis, 2013).
  • The diagnosis and treatment of tongue-tie and other complications that impact breastfeeding should be basic competency for all physicians and pediatric dentists (O’Callahan, Macary, & Clemente, 2013). In order to achieve this, a universal definition, examination method, and classification system for tongue-tie should be established.
  • Finally, instead of waiting until breastfeeding challenges arise, lactation consultants and physicians could adopt a more proactive approach to assessing tongue-tie. In Brazil, national law requires all newborns to be screened for tongue-tie using a universal, empirically validated assessment tool (Martinelli, Marchesan, & Berretin-Felix, 2012).

Research demonstrates that breastfeeding practices improve rapidly when appropriate lactation support is offered (Rollins, et al., 2016). Mothers experiencing difficulty breastfeeding need greater access to these resources. When breastfeeding is not made difficult by complications, it can actually serve to protect maternal mood by lessening reactivity to stressors and inducing calm (Groer, Davis, & Hemphill, 2002). Enhancing support for mothers who want to breastfeed can ultimately play a role in improving maternal mental health.

Resources

If you are experiencing difficulty breastfeeding, you are not alone in your struggle. The following resources are available:

Breastfeed LA offers a free/low cost resource directory for lactation services in the Greater Los Angeles Area.

Women, Infants, and Children (WIC) provides breastfeeding support to pregnant and postpartum women in need of free or low cost services. You can use their online prescreening tool to determine whether you are WIC eligible.

If you are looking for an International Board Certified Lactation Consultant (IBCLC), the International Lactation Consultant Association (ILCA) offers a directory to find one in your community.

La Leche League International offers free local meetings, a national breastfeeding helpline, and many other resources for breastfeeding mothers in need of support.

References

The Academy of Breastfeeding Medicine (2004). Protocol #11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf.

American Academy of Pediatrics and American Society of Pediatric Otolaryngology (2016). Tongue-tie in infants and young children. Retrieved from https://www.healthychildren.org/English/healthy-living/oral-health/Pages/Tongue-Tie-Infants-Young-Children.aspx.

Benyo, A. (2015, May 26). I know all about the ACA’s breastfeeding benefit, and I couldn’t get services covered. Retrieved from https://nwlc.org/blog/i-know-all-about-aca’s-breastfeeding-benefit-and-i-couldn’t-get-services-covered/.

Brown, A., Rance, J., & Bennett, P. (2015). Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing, 72(2), 241–481. doi:10.1111/jan.12832

Davis, L. S. (2013, Jan 2). Is the medical community failing breastfeeding moms? Retrieved from http://healthland.time.com/2013/01/02/is-the-medical-community-failing-breastfeeding-moms/

Farver, M. (2016). A model for outpatient lactation care. MOJ Women’s Health 2(2). doi:10.15406/mojwh.2016.02.00025

Fernando, C. (1998). Tongue-tie—from confusion to clarity: A guide to the diagnosis and treatment of ankyloglossia. Sydney, Australia: Tandem Publications.

Groer, M. W., Davis, M. W., & Hemphill, J. (2002). Postpartum stress: Current concepts and the possible protective role of breastfeeding. Journal of Obstetric, Gynecologic & Neonatal Nursing, 31(4), 411-417. doi:10.1111/j.1552-6909.2002.tb00063.x

Hannula, L., Kaunonen, M., & Tarkka, M.-T. (2008) A systematic review of professional support interventions for breastfeeding. Journal of Clinical Nursing, 17(9), 1132–1143. doi:10.1111/j.1365-2702.2007.02239.x

Martinelli, R. L., Marchesan, I. Q., & Berretin-Felix, G. (2012). Lingual frenulum protocol with scores for infants. The International Journal of Orofacial Myology, 38, 104-112.

O’Callahan C., Macary S., & Clemente S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology, 77(5), 827-832. doi:10.1016/j.ijporl.2013.02.022

Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., Piwoz, E. G., Richter, L. M., & Victoria, C. G. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet, 387(10017), 491-504. doi:10.1016/S0140-6736(15)01044-2

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10 Permissions for Pregnancy After Loss

10 Permissions for Pregnancy After Loss

It is my hope that this blog post will offer validation, solace, and hope to the strong, resilient women who find themselves pregnant after experiencing the devastating loss of a baby due to miscarriage or stillbirth.

Unfortunately, the conversation regarding pregnancy loss is still taboo in our culture. Despite the fact that up to twenty percent of known pregnancies end in miscarriage, women and their partners often feel isolated in their grief, suffering immeasurable pain in silence. These feelings may become even more complicated during a subsequent pregnancy.

Pregnancy after miscarriage or stillbirth can be painful and frightening. You may alternate between conflicting feelings of joy and sadness as you expect new life while mourning another. You may be overwhelmed with worry that you will lose again, finding it difficult to connect with your pregnancy. All of these feelings are normal. Adapted from Lindsey Henke’s ideas, see below, I offer the following ‘permissions’ to women experiencing pregnancy after loss:

10 Permissions for Pregnancy After Loss

  1. It is okay to feel detached from this pregnancy. This is your way of maintaining a safe emotional distance. The idea of becoming attached and losing again is unbearable.
  2. Be kind to yourself. Offer yourself the same compassion and nurturance you would to someone else who just lost a loved one.
  3. Surround yourself with an empathic support system including family, friends, other bereaved mothers, mental health providers, and your pregnancy care team.
  4. Choose to announce and celebrate this pregnancy or not. Trust your intuition when deciding whether or not a celebration is right for you.
  5. If you need, decline invitations to baby showers, birthday parties, or other events that may be triggering to you. It is not rude; it is a form of self-care.
  6. If you need, take a break from social media. It can be incredibly painful to see photo after photo of pregnant friends and babies.
  7. Give yourself permission to grieve and connect with feelings of sadness, anger, and fear.
  8. Allow yourself to feel joy and hope for the new life you carry. Connecting with this baby does not mean you have to forget about the one you lost.
  9. Do whatever YOU have to do to seek healing. This may mean honoring your loss through a ritual—such as planting a tree, writing a letter, or lighting a candle—or choosing to do nothing. For some, a ritual might be too painful. Do what is right for you.
  10. Remember this is a different pregnancy, with a different baby, and a different outcome.

You have experienced unimaginable pain, and it has likely left you raw and vulnerable. Yet in this tender, opened-up state, you will connect with those who offer love and support in a profoundly healing way. Furthermore, you have gained empathy for others who have known suffering and loss. This openness and understanding will prepare you for parenthood and the vulnerability involved in wholeheartedly loving your child.

In Dr. Elisabeth Kübler-Ross’ words: “The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern.”

Resources

I was recently honored to connect with Lindsey Henke and Kiley Hanish, both of whom founded organizations to help reduce the stigma of pregnancy loss and stillbirth while raising awareness and instilling hope in bereaved mothers. Below I have provided links to their resources for healing after loss.

Lindsey Henke is the founder and Executive Director of Pregnancy After Loss Support (PALS). After giving birth to her stillborn daughter, Nora, she founded PALS in order to support women during the painful and complex experience of pregnancy after loss. She is also the author of Stillborn and Still Breathing, a blog about her journey through grief after child loss.

Kiley Hanish is the founder of the Return to Zero Center for Healing, which provides outreach, education, and research to instill hope and initiate healing after the death of a baby. Kiley and her husband Sean created the Emmy-nominated film, Return to Zero, based on their personal experience of giving birth to their stillborn son, Norbert. Kiley also developed the Pregnancy Loss and Infant Death Directory, which connects bereaved families with local resources.

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Five Stages of Postpartum Depression

Five Stages of Postpartum Depression

I recently read an article likening the experience of postpartum depression to that of grief. Katherine Stone, who won a Media Award from Mental Health America for her blog post, applied Kübler-Ross’ five stages of grief to PPD. As a therapist who treats mothers struggling with postpartum depression, it is also my experience that the process is met in stages, similar to grief. Each phase unearths new feelings and different struggles.

Kübler-Ross’ five stages of grief are as follows:

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

These stages are not typically passed through linearly; rather, one moves through them in waves, without order or timeline. Like grief, each person experiences postpartum depression differently. This is important (notice the italics). You cannot expect your symptoms of postpartum depression to follow the same course as someone else’s. What worked to alleviate their PPD may not work for you, and visa versa. What initiates your recovery may not have worked for them. We do not put expectations on grief, and in the same way, we cannot put them on postpartum depression. Here is an example of what each stage may look like:

  • Denial: “This is not postpartum depression. Motherhood is just not as easy for me as it is for others. Once I start sleeping more this will improve.”
  • Anger: “Why do other moms look like they’re enjoying every minute with their babies, and I’m miserable? I shouldn’t have to seek treatment for this!”
  • Bargaining: “Maybe if I start scheduling a little more ‘me’ time I’ll start feeling better. Maybe this will pass once my baby turns one or starts sleeping through the night.”
  • Depression: “My family deserves better than what I can give them.” It is extremely difficult to ask for help when you are in this stage. Not only do you feel unworthy of help, but you also don’t have the energy or motivation to seek it. This is the time you may start to question if you’re family would be better off without you or even feel suicidal. Remember, you are not alone, and these symptoms are treatable.
  • Acceptance: “This is temporary. I will not feel this way forever. I don’t have to be miserable!” This stage usually comes once you’ve sought treatment, found relief, and discovered you are not alone in your feelings.

With help, you will reach acceptance, and you will find recovery. As Katherine so eloquently asserts: you will feel the love for your child that was always there, temporarily buried by postpartum depression. The pleasure and enjoyment of motherhood will surface once PPD is effectively treated. A temporary inability to access this joy does not make you a bad mother. It merely means you are one of many who are struggling with postpartum depression—one in five to be exact. You are not alone. What you are feeling is common. What you are feeling is treatable.

 

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The Baby Blues and Postpartum Depression

Baby Blues & Postpartum Depression

Dearest New Mama,

You have just given birth. In accomplishing this feat, you are empowered, yet exhausted, and now tasked with life’s most important responsibility—caring for your baby. Amidst this sudden change, you may find yourself feeling sad, anxious, or irritable. These feelings can be distressing, as you expected to be basking in the glory of motherhood; however, what you are feeling is normal. Eighty percent of new mothers will experience the Baby Blues, and twenty percent will experience Postpartum Depression. This means you are not alone! After giving birth, levels of estrogen and progesterone plummet. This sudden crash may trigger “blue” symptoms. Baby Blues Connection, an online resource for new moms, suggest women may experience some or all of the following symptoms:

  • Frequent crying
  • Feeling let down
  • Impatience
  • Irritability
  • Restlessness
  • Anxiety

Symptoms usually remit after two weeks as your hormones begin to adjust. If you find your symptoms worsen or continue after a few weeks, you may want to be assessed for Postpartum Depression. PPD is less common than the Baby Blues, but is still experienced by 1 in 5 moms. It can be hard to differentiate between the two, as they share many of the same symptoms. Postpartum Depression, however, is longer lasting and more severe, sometimes making it difficult to care for your baby. While it looks different for every mom, here are some of the most common symptoms:

  • Frequent crying or unrelenting sadness
  • Loss of interest daily activities
  • Appetite and sleep disturbances
  • Intense guilt or shame
  • Emotional numbness
  • Anxiety, irritability, and restlessness
  • Intrusive thoughts of harm coming to your baby
  • Sometimes, even thoughts of death or suicide

Unlike the Baby Blues, Postpartum Depressive symptoms usually do not remit on their own. Therefore it is important to reach out for help if you think you may be struggling with depression following the birth of your baby. If you feel safe, confide in your partner, a family member, or a close friend. You may also choose to work with a therapist who can validate your experience and help you alleviate these symptoms. Seeking help in a time of need is difficult, as we feel exposed and vulnerable. Remember, what you are experiencing is common, treatable, and temporary.

In the mean time, try to find little ways to sneak in self-care. When you have a free moment (albeit they are few), soak in a bubble bath instead of your usual five-minute shower. Enjoy a hot cup of coffee or tea. If you can, get outside and take in fifteen minutes of sunlight. Eat a warm, balanced meal instead of the cold pizza in the fridge. We sacrifice so much for our babies, even at the expense of our own physical and mental health. Now is the time to ask for help if you need it.

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