Vital Signs: Ignoring postpartum depression and psychosis won’t make them go away

Another horror story. Another mom. Three beautiful girls who will never have another birthday, whose last memory will be terror at the hands of the person they trusted the most.

I don’t know the details. I don’t really want to know the details. I do know that this mother reached out, told her own mom she was “feeling crazy”. I do know that she had three babies in a row, and that the youngest was 2 months. I do know that there’s a strong chance that this was the result of postpartum psychosis.

And I know that this has got to stop.

Can we protect every family, prevent every case? Of course not. But postpartum mental health is taking a backseat when it should be sitting shotgun to every maternal and child health program. That’s a start, at least. We spend so much time worrying about a woman’s breasts, while we dismiss her mind. We worry about how hormones and birth practices affect lactation, while we disregard how they affect our emotions.

After we give birth, we are whisked off to the maternity ward. Our vital signs are monitored, but other vital signs are ignored. A mom who can’t seem to connect with her baby. Who is scared, and asking for help. Who is alone and voiceless. Her pulse may be steady, but her hands shake. Her breasts may leak colostrum, but her eyes may leak silent tears. And we ignore this.

GE-Healthcare-Dash-2500-v4-Vital-Signs-Monitor

OB/GYNs don’t see mothers until 4-6 weeks postpartum. In some cases, that will be too late.

Pediatricians see moms with their newborns several days postpartum, but they are focused on the infant. As they should be. We don’t expect a heart surgeon to be concerned with the diabetic foot of his cardiac patient’s wife.

When I see the role of lactation consultants and breastfeeding counselors growing, gaining more attention, more insurance coverage, I also see an opportunity. What if these professionals could be trained to screen for postpartum mental health issues, if they could recognize red flags and know how to refer families to the proper resources? What if they were trained to support families in their feeding journeys, with the goal being a happy, healthy family and not just a breastfeeding statistic?

With the state of our health care system, I don’t expect that an entirely new support staff can be instilled at every hospital, for the sole purpose of protecting maternal mental health. But when 1 in 7 mothers suffer from postpartum depression or anxiety, I think that constitutes just as much of a public health concern as the supposed risks of “sub-optimal breastfeeding practices” in developed countries. If we are going to focus so heavily on breastfeeding, could we at least give a little simultaneous attention to a mom’s mood while we inspect her breasts?

What happened to the Coronado family is sub-optimal. What passes as “support” for postpartum women is sub-optimal. There is no reason we can’t support breastfeeding while prioritizing maternal mental health. Both are important, but one has been systematically ignored, shoved under piles of paperwork, given lip service. We only seem to worry about postpartum depression in terms of how it affects breastfeeding “success”. There are so many things wrong with that sentence, with that mentality. It’s like worrying about prostate cancer only in terms of how it will affect sex and procreation. Biological norms are important, but support also means protecting those whose biology turns on them.

If we can only speak of maternal needs under the umbrella of lactation support, I can live with that. As long as those needs are met, I can live with that. As long as those needs are being met, maybe we can all live with that.

Survive with that.

Thrive with that.

 

 

Can breastfeeding concerns be overcome with support? Depends on what “support” means

Guess what? Women are having trouble meeting their breastfeeding goals.

Contain your excitement.

Apparently, this is news to the American Academy of Pediatrics, and every major news outlet in North America. The study causing such shock and awe came out this Monday in the journal Pediatrics. Researchers used self-reported data (i.e., interviews) from 532 first-time moms giving birth at a particular medical center (can’t find where, and due to geographical differences in levels of breastfeeding support and acceptance, I think this is vital information that at least one of the articles could have shared with us). The women were asked prenatally about their breastfeeding intentions and concerns, and then re-interviewed at 3, 7, 14, 30 and 60 days postpartum. According to Reuters:

During those interviews, women raised 49 unique breastfeeding concerns, a total of 4,179 times. The most common ones included general difficulty with infant feeding at the breast – such as an infant being fussy or refusing to breastfeed – nipple or breast pain and not producing enough milk.

 

Between 20 and 50 percent of mothers stopped breastfeeding altogether or added formula to the mix sooner than they had planned to do when they were pregnant.

 

Of the 354 women who were planning to exclusively breastfeed for at least two months, for example, 166 started giving their babies formula between one and two months.

 

And of 406 women who had planned to at least partially breastfeed for two months, 86 stopped before then.

Given these results, the study authors come to the conclusion:

Breastfeeding concerns are highly prevalent and associated with stopping breastfeeding. Priority should be given to developing strategies for lowering the overall occurrence of breastfeeding concerns and resolving, in particular, infant feeding and milk quantity concerns occurring within the first 14 days postpartum. (Source: Pediatrics)

 

The headlines, as usual, were both amusing and infuriating. “Nursing Troubles May Prompt New Moms to Give Up Sooner”. “Early breastfeeding challenges make women quit.” “Some moms discontinue breastfeeding within two months die to nursing difficulties”. And my personal favorite, “95% of breastfeeding problems are reversible.”

One might easily blame the media for their usual skewering of the science to make for a juicier headline, but one can hardly blame them when the experts giving interviews about this study say things like, “It’s a shame that those early problems can be the difference between a baby only getting breast milk for a few days and going on to have a positive breastfeeding relationship for a year or longer… If we are able to provide mothers with adequate support, 95 percent of all breastfeeding problems are reversible.”

So, what’s my issue? I think the study is fine. Sort of a no-brainer, considering they could’ve came to the same conclusion years ago had they just listened to moms instead of insisting we just needed more convincing of the benefits of breastfeeding, and we’d all magically lactate to the satisfaction of the World Health Organization. But the quote above (from Laurie Nommsen-Rivers, one of the study authors) makes me wonder if the results of the study are being taken in the wrong context.

The focus is on moms not getting enough support –  something that I 100% agree needs to be focused on. Like, yesterday. But where the experts quoted in these articles and I part ways is on what type of support is needed. This passage from NPR illustrates my point:

The researchers didn’t do physical exams of the moms and babies, so they don’t know what was happening for sure. But they speculate that some of the first-time mothers may have misread the babies’ cues, mistaking fussiness for hunger, for instance, or thinking the babies weren’t getting enough milk when they’re doing just fine…

 

Once again, the assumption is that women are wrong about their bodies, and about their babies. The study authors surmise that access to lactation consultants in the first week postpartum, after hospital discharge, will be the solution to many of these problems. Again, I absolutely agree that this is a great start. And yet – reading through the scores of FFF Friday stories, I have to wonder… is this really going to make a difference, given the current state of our breastfeeding culture? How many LCs have we all seen, cumulatively? How many were bullied or shamed by medical professionals? How many of us have been told our babies were fine, only to end up in the ER with a dehydrated infant? How many of us were told – by professional lactation consultants and pediatricians – that every woman can breastfeed, and that we should just keep on nursing and it will all work out?

Looking at this study, this is what I see: a ton of women are claiming to have pain, trouble latching, and concerns that their babies aren’t getting enough milk. NPR also reports that the group with the least amount of reported problems was comprised mostly of women under 30, and women of Hispanic origin. That begs for further research, doesn’t it? Could age and legitimate lactation failure be associated? What about race/ethnicity? Are there conditions more prevalent in older, non-Hispanic populations that are also associated with breastfeeding problems?

And this is what I also see: We have an opportunity – no, a responsibility- to look at the type of support these women are getting. Is it truly evidence-based? Or is it based on dogma; on the belief that “95% of breastfeeding problems are reversible”? (By the way, I am super curious about the research backing up that claim.) Are the individuals giving the support truly listening to the mothers, examining them, considering the delicate balance of hormones necessary for lactation, or the effect of emotional or physical trauma around birth on a woman’s ability to withstand latching pain or her infant’s cries? Is there nuance? Are these mothers being seen, or are they being treated as uniform breasts, needing to be “handled” so that they can fulfill their duty of providing exclusive breastmilk for 6 months?

I’m not knocking a study that advocates for more support for moms. I simply want us to open up the discussion, rather than going in circles, with the same researchers and the same experts telling us the same things – if mothers only knew better. If they could only be taught to recognize their babies’ cues. If they would only listen to us. 

I think it’s time they listened to us, instead. Which brings me to what I’d really like to see from this study: a follow-up where they ask the women who “failed” to meet breastfeeding recommendations what they think would have helped them reach their goals. Because without that piece, I really don’t think we can get very far.

 

FFF Friday: “Didn’t I have a right to know that I might not be able to breastfeed and why?”

Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They also are not political statements – this is an arena for people to share their thoughts, and I hope we can all give them the space to do so.


I was in need of a good laugh today, so I thought I’d share this fantastically funny FFF Friday submission by Melissa.  I’m betting you’ll find her writing as witty as I did, but be warned – underneath the humor is a scathing indictment of what often passes for professional breastfeeding help. If you concern yourself with women’s healthcare, this post will likely hit you in the gut: first because you’ll be belly laughing, and second, because you’ll be as angry as Melissa over the sub-par level of care – and lack of honesty – she experienced while trying to breastfeed her daughter.

Happy Friday, fearless ones…

The FFF
***
My daughter was due November 8, 2011, so naturally being her father’s daughter, I arrived at the hospital on November 21st for an induction. I spent the first day (8 hours!) on pitocin (and nothing else) and…. nothing happened.
I’m trying really hard right now to keep this to my boobies and not write about everything else that happened and that still angers me about my birth experience. Let’s just say that the last thing a CNM should say to a lady who has been on pitocin for 8 hours without an epidural is to question whether said lady actually wants to have this baby and tell her she needs to visualize having the baby and think about what is emotionally blocking her from giving birth to the baby, as though one can think POOF! World Peace!
Ahem. Fast forward, the next morning, I was again on pitocin until I called uncle around 1 PM and got an epidural. Then things got exciting.
By 9 PM, I was ready to push.
By 10 PM, pushing had done nothing.
By 11 PM, baby’s heart rate was doing a weird dance with every push.
By 12 PM the drugs were off and I was being prepped for a C-section.
At 2:03 AM, November 23rd, little E finally made her grand entrance into this world.
By 2:15 AM, Mommy had proceeded to completely lose her shit over things the doctor said while putting her back together, and someone was kind enough to drug her up well and good such that she thought she was in New Orleans on Mardi Gras when she woke up in recovery….
E figured out the latch thing immediately, and I thought we were cruising. Sure, it hurt like hell and someone probably should have brought me a nipple shield before she turned the left nipple into a bloody mess, but I was expecting all this. I was okay with all this. I was patiently waiting for the milk to come in, feeding her every 2-3 hours, loving watching her sweet little face and hands at such a close distance… And everyone said that it takes longer for your milk to come in after a c-section, so I wasn’t worried when I had no milk by day 2. I figured I had colostrum, she’d eat that, and the (still the same size as before I was pregnant) boobies would do their thing.
By day 3, the nurses had taken to checking in with us every half hour to see if E had peed yet (she hadn’t). And she was rather orange, even to my untrained eye… By then I’d started pumping between feeds on the lactation consultant’s (number 1!) advice, you know, to speed things along because my milk was totally coming… E was angry, screaming, and sucked away on my breasts like there was no tomorrow. She’s more efficient than a pump, they said, so when she fell asleep on the boob that must have meant she got something to eat first, right?
Then the nurses started in with the jaundice talk and someone said she might just need to stay an extra day after I was discharged, you know, if she was still yellow. And that was a wake-up call, because after two days on pitocin without an epidural and an unexpected c-section, I’ll be damned if I’m leaving the hospital without my trophy-baby to show for it. I think we called up the nurse right then and there and brought in a bottle of formula. E sucked it down like she had been starving. Because, you know, she was. By this point she’d lost a full pound of her 7 pound 12 ounces weight.
We left the hospital the next day with E and a hospital grade pump. I pumped. And pumped. And pumped. I hired a new set of lactation consultants (number 2!) who came to my house, weighed E, put her to boobie (she latched on, perfect), then weighed her after 45 minutes on each boobie (no change in her weight at all). They looked at me. They looked at boobies. They made notes. They discussed. They mentioned words to each other that I’ve never heard of, like “IGT” and “tubular” and “one is significantly larger than the other”… and never once did they mention that this might mean I wouldn’t ever get enough supply to feed my baby.
I kept on with the pumping, because new lactation consultants thought it would increase supply. I bought supplements. I drank massive amounts of water in hopes it would clear up massive c-section swelling (did I mention, I still couldn’t bend my knees?). Finally, on day 6 after the birth of my daughter, I got something resembling milk from one boobie… and on day 7, something resembling milk from the other boobie. Success!
Except, my boobs were still the same size. They never got bigger. And I continued to pump and pump and pump and pump… and nothing changed. New lactation consultants (number 3!) were called. Lactation consultant number 2 texted me questions to see how it was going, and when I told her I was pumping every time after she nursed, and still getting just trickles, she offered things like a clear plastic tube attached to a syringe to supplement with the formula I was already giving E. Or to come let me rent her scale for a weekend. Or to come back and do a weight check. Or double check the latch. Or something.
By week 2, I was a mess and my supply had not increased.
By week 3, E had gone on strike agains the boobies, refusing to latch on at any time other than 4 AM after our longest stretch of sleep (when they were most likely to have gotten enough stored up for her to be happy for a little bit). So I pumped and pumped… By the end of Week 3, I was pumping every three hours and E was eating 90% formula and 10% what I made.
By week 4, that had changed to 95% formula and 5% what I made.
By the end of week 4, I had an allergic reaction to the supplements and stopped them cold turkey. My “supply” tanked – I went from making a total of 3-4 ounces a day to less than 15 ml. a day.
At that point, I’d had it. I was tired, I wasn’t enjoying my daughter, and I found myself on Christmas morning strapped to a pump in our living room while my husband made silly noises over our baby and drank his coffee. I stopped cold turkey a few days before New Years, and dried up almost immediately. No pain, and boobies were still the same size as before I got pregnant. I was sad, but resigned, figured it was the long labor or c-section, or all of those things that had made breast feeding not work.
Then I started researching.. and I figured out what IGT was. What tubular breasts were. What those words the lactation consultants had mentioned to one another meant. That I might never have gotten enough supply in, even had I not had a c-section or been swollen beyond recognition. Even if I had woken up that extra hour early during our one 4-5 hour sleep stretch every day. Even if I hadn’t supplemented with nasty formula in the hospital. And every single one of the warning signs listed for IGT, I had in spades. My boobs have always been different sizes, with the left larger than the right. Yes, they are tubular, not that I knew that but I had always known they weren’t a full as the Barbie-like ones I saw on TV. And they didn’t change size at all during pregnancy. Boy, was that a warning…
And then I was angry. Because these ladies I had hired to help me breast feed, every single one of the three different consultants I hired, they either knew or should have known, and didn’t I have a right to know that I might not be able to breast feed and why?  How dare they not tell me. How dare they assure me that these steps I was taking would increase my supply, just keep trying, keep doing, keep putting her to breast even when she is screaming-hungry.
I look back on those first few weeks with regret; if I had known that my boobs were tubular, that the lack of growth during pregnancy (and after birth!) might mean something regarding supply, that never feeling engorged, or feeling really much of anything, might indicate the milk just wasn’t there and wasn’t going to be there, would I have wasted so much time with the pump instead of spending it sleeping or cuddling my daughter or recovering from major surgery? Would I have spent so much time feeling guilty and debating stopping the crazy pumping schedule? Would I have felt so guilty when I decided enough is enough?
E is almost 5 months old now. She’s hitting every one of her milestones early; she’s been in daycare since mid-February and has had precisely one cold, and she barely noticed it. She’s the happiest, sweetest little girl, and she’s 85th percentile in height and weight. And most importantly, she’s a good eater, a good sleeper, and she’s healthy.

When it comes to lactation consultants, compassion is what makes the difference

I’ll admit it: I’ve been neglecting the blog lately. Blame it on my being out of town, or maybe on the fact that I have 2 weeks in which to make the final edits before my book goes to print, but in all honesty, it’s simply because I haven’t been all that inspired to write about anything.

Until 5 minutes ago, when I read one of the most infuriating opinion pieces that I’ve ever seen in print.

The column, written by an Illinois lactation consultant, exemplifies everything that is dead wrong about the business of breastfeeding. My heart hurts for the many truly amazing, considerate LCs I’ve met over the years who are going to be judged on the hurtful words of someone who shares their profession, but shares none of their compassion.

“What is it that makes one mother work so hard to breastfeed?  What is it that makes another one give up at the first hint of challenge?”This lactation consultant ponders aloud. If this weren’t inflammatory enough, she elaborates:

There are women I will never forget.  The one who pumped her milk for a year, because her little one could not get any milk from the breast.  The one who vomited into a bowl while I held her baby on her breast, telling me, “Don’t take her off!”, when I tried to remove the baby from the breast.  And there was a mom who nearly died after giving birth. When she was taken off the ventilator days later, her first words were, “Bring me a breast pump.  I need to feed my baby.”

…I carry with me the mother who quits breastfeeding after the first breastfeeding attempt.  I am sad for the baby who is not given a chance…But those babies who are given a chance… Wow. What lucky little people they are….What is the difference?  What makes breastfeeding so important to some people, and not to others?  What is that we are “made of” that determines who gets breastmilk and who doesn’t?….I want to figure that out.”

Apparently, I have something in common with this person: I also want to figure something out.  I want to figure out when it became a good thing that a woman’s first impulse after a near death experience is not to hold her child or tell her husband she loves him, but rather to secure a breast pump. I want to figure out when it became okay for a professional to publicly berate women for not being “made of” the right stuff simply because they don’t go to incredible (some may even say obsessive) lengths to breastfeed. And most of all, I want to figure out how someone so clearly judgmental and shockingly dogmatic ended up in a care profession. 
On the other hand, maybe defining LCs solely as care providers isn’t 100% accurate or fair. According to the International Board of Lactation Consultant Examiners, their board-certified lactation consultants should “function and contribute as members of the maternal-child health team. They provide care in a variety of settings, while making appropriate referrals to other health professionals and community support resources. Working together with mothers, families, policymakers and society, IBCLCs provide expert breastfeeding and lactation care, promote changes that support breastfeeding and help reduce the risks of not breastfeeding.” Going by this definition, LC’s are indeed care providers, but at the same time, one of their main purposes is to “help reduce the risks of not breastfeeding.” If one were to take that responsibility to heart, then a mother who stops at anything short of martyrdom to breastfeed is going to be seen as an occupational hazard. Luckily, the good lactation consultants are so much more than this explanatory paragraph describes. They can be invaluable sources of advice, support, and yes, caring. 
I wonder if an LC who places greater emphasis on finding a feeding method that works for individual situations would be considered less of a success than someone like the author of the aforementioned, ridiculously insulting piece? Would and LC’s motives be questioned if she told a woman it would be okay to formula feed? Would this be considered a subtle form of malpractice?
We’ve discussed the concept of “feeding consultants” (a hypothetical professional who could provide support to parents regardless of feeding method, helping them to exclusively breastfeed, combo feed, pump, or formula feed, depending on the needs of the family) in some of our discussion threads here on FFF, and the more I think about it, the more I wish something like this could exist… and the more I  realize it probably never can. A lactation professional who would just as easily encourage a woman to formula feed is never going to be taken seriously as a breastfeeding counselor. She’d immediately be dismissed as “sabotaging” breastfeeding, even if she were merely listening to her client/patient and assessing her needs; even if she were looking at the nursing dyad as a true dyad, and not as two fleshy feeding receptacles and a stock image of the ideal newborn. 
If there are any lactation consultants reading this blog, I would love to hear from you. What do you think of the Illinois LC’s column? Do you think it’s possible to be a formula-friendly lactation consultant? And if not, do you still believe that lactation consultants should be giving formula feeding advice, as this thoughtful post over on PhD in Parenting suggests?
I hope we can get some sort of positive dialogue going about this, in order to mitigate the pall of sheer disgust that the author of this article has flung upon all non-breastfeeding mothers. I would like to remind said author that someone who didn’t breastfeed the first time may be doubly dedicated to making it work the second time around; if you truly want to raise breastfeeding rates and help women succeed in their goals, you may want to reassess your world view. Because when it comes to being a good and effective lactation consultant, as well as a compassionate human being, realizing that you may not fully understand someone else’s lived reality is, in your own words, what makes the difference.

Breastfeeding Problems: Finding the right approach

I got an interesting email from genuinely fearless lactation consultant Valerie this morning, posing the question: when helping new mothers who are attempting to breastfeed, where should the line be drawn between encouraging positivity and realistic practicality?

She writes:

Occasionally in the hospital setting I will run across a situation when maternal anatomy makes clear that breastfeeding will not be easily accomplished. (To a lesser degree, there are situations such as “late pre-term” babies, tongue tie, or just uncoordinated suckle on the part of the baby – all of which make the startup a bit more complex.)

I find myself struggling between wanting to give a realistic picture of what may be required to give breastfeeding a chance vs. sounding too discouraging.

The most recent situation encountered yesterday that inspires my question: A mom I was trying to help has the type of nipples that do not easily compress for a baby to latch onto. The best way for me to describe them is that they are “fibrous” or feel almost like scar tissue. Little to no flexibility and a wide diameter so not easy for a baby to learn to latch onto. She had attempted with her first child briefly. Interestingly, there was even a charted feed with this child post delivery. (I highly doubt this child was latched at all based on my assessment of her nipples!) The primary nurses rarely touch a mom’s breasts or nipples so seem largely unaware that this type of nipple is not going to be easy to latch onto or that they even exist!

This mom had come in intending to do “both” (bottle/breast). This can certainly complicate a one or two day old baby’s willingness to feed in the average situation – depending on ease of latch and volume of formula given. (I know that some people call it nipple confusion – I think the baby is not confused at all – – bring on the milk!) 🙂 But her prior experience had her knowing that things were unlikely to be simply “latch and feed” so she knew what she would likely need.

Once the baby was awake and interested enough, it becomes easier to assess whether the baby was capable of latching – at least at this feed. In this case, as soon as I touched mom’s nipples (with permission granted 🙂 I saw that this would be no quick fix or a “just wait for the baby to wake up” fix. We tried a nipple shield for a few minutes without much success. I offered some suggestions to the mom about what options would be available in the short term – such as pumping – since the milk was coming – latch or no latch. With no milk removal, the supply would go. She affirmed that with her first child, she did experience engorgement.

I left the decision up to her as to whether she would like to begin pumping and / or continue to try on her own or with my help at successive feeds. (She had already given two bottle feeds since she’d been unable to latch baby on her own.) She had gone to the WIC breastfeeding class and seemed to want to try again with this child. I encouraged her to think about what she’d like to do if the baby continues to be unsuccessful in latching, and I would be happy to help her when she called. (Did not want to have her feel pressured at that moment – and wanted her to have time to think about it.) I don’t think she’d thought about pumping for bottles – even short-term – so I mentioned that some women do this for as long as they felt it was working for them. (Again – my personal opinion on this is to educate moms about how to do it, and acknowledge that it is often cumbersome and tiring – but possible for some moms who want to.) But even my suggesting this at this point made me wonder if I am indicating that I don’t think latch looks promising….

So – bottom line question. Do most moms want a realistic picture of what may complicate the breastfeeding success curve in the early days? Or that it may actually be impossible to latch a baby until the baby is possibly weeks old? As an LC, I certainly cannot predict what will happen, but sometimes it is obvious that success is not going to be quick or easy. I struggle between wondering if I should be realistic about what will likely happen without ending up being too discouraging in case the baby makes a liar out of me.

Besides making me wish I’d had a lactation consultant like Valerie in the hospital where I gave birth, this email made me think. If you had some physical condition which **might** make breastfeeding challenging, would you want to know beforehand?

Now, I think it’s pretty obvious where I stand on this; I believe forewarned is forearmed, and it is one of the reasons I write this blog, and encourage you all to share your stories every Friday. I’ve learned so much about lactation problems in the past 2 years, and as any regular reader of FFF can tell you, these issues are real, relatively plentiful and seldom talked about by medical professionals. In many cases, the problems aren’t insurmountable, but when a woman is a few hours postpartum or a newborn is losing precious ounces by the hour, it’s hard to find a calm resolution. Going in with knowledge of what you might be facing could help you be in the right state of mind, with the right folks on your team; you could do your research and not be at the mercy of whoever is on call from the LC team that morning (because god knows, it probably won’t be Valerie).

On the other hand, there’s that whole power-of-positive-thinking thing. Maybe ignorance really is bliss? If it’s a problem that may not even turn out to be a problem, could worrying about it do more harm than good?

Considering how many of us had physical impediments to lactation, I think we’re a perfect sounding board for any professional pondering these issues. So I’m asking you, FFFs – what do you think? If you were the woman in Valerie’s story, how would you prefer she handle the situation? Harsh realism, blind positivity, or something in between?

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