FFF Friday: “My real argument is my son’s life.”

 

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 feelings, and I hope we can all give them the space to do so. 

Before you read Reese’s story, I want you to do me a favor: look at your children. Reflect on their beauty, their quirks, their uniqueness. They are people – not petri dishes. They have worth beyond their statistical probabilities, beyond what your choices for them represent politically. And realize that you are not a petri dish, either. All the studies in the world can’t tell us the first thing about your story, your worth, or what is in your heart.

Now read the story below, and welcome the chills you’ll get at the end (and they will come, I promise). 

Happy Friday, fearless ones…

The FFF

***

Reese’s Story

I might be the ultimate target for mommy judgment.  I divorced, got pregnant, and remarried at the age of 37.  I was induced at 37 weeks, then went straight to a C-section when the baby’s heart rate and my blood pressure plummeted.  Now my one-year-old son wears disposable diapers and rides in a stroller and sleeps in a crib.  He eats store-bought baby food and drinks formula.  We feed him when he wakes at night, though his pediatrician and half the internet says we should have sleep-trained him by now.

Before your fingers start itching to type, before you act on that “oh no, what if SHE DOESN’T KNOW?” feeling, before you decide it’s your responsibility to educate me, let me tell you the worst part.

I exposed my baby to prescription medication in utero. And if I’m astonishingly lucky enough to have another child, I’ll do it again.

But anonymously on the internet is the only way I will ever discuss this, outside my immediate family.  Only my doctors know.

The other day my husband was talking with a pregnant mom who wanted an all-natural pregnancy, but her headache got so bad she took a Tylenol.  She felt horribly guilty.  My husband wanted to say, “you’re totally fine.  No, trust me, you’re FINE.”  But then he would have to explain what he meant.  So instead, I’ll take this space here to explain.  Maybe some other mom who is feeling horrible will get some comfort from my story.

My son is almost one year old.  He’s achieving milestones, getting into everything, and showing signs of being an opinionated, fiendishly clever little guy.  Strangers comment on his huge eyes, always watching and absorbing everything.  He plays peekaboo and climbs on the furniture and yells “di di di di!” chasing the dog.  He “plays” piano and sings along, he giggles at jokes, he loves strawberries, and he’s obsessed with opening and closing doors.  While he’s on the small side (25th percentile), I can’t really call that a problem because I never broke the 5th percentile when I was growing up.  He’s doing a pretty darn good job of growing, given his mom’s genes.

Unfortunately my genes also gave me an unrelenting chronic disorder, one that I’ve had my entire adult life.  I always assumed I’d never be able to have kids.  I’ve earned a Ph.D, taught at a university, managed employees and programmed computers and raised funds and conducted research, all while taking the heavy-duty medication that keeps me alive and functional.  But I never thought having a baby would be among my accomplishments.

Then I met a wonderful high-risk OB, probably the best doctor I’ve ever seen (and I’ve seen a lot).  She said my hormone levels didn’t look good, that I’d likely have trouble conceiving.  But then she said “actually, we can work with your medication. We would start tapering in the second trimester, and get you down to as low a dose as you can handle.  If the baby is born with signs of drug dependence, the neonatal team knows exactly what to do, and we’ll get you both through it.”

My boyfriend and I knew we didn’t have much time.  Armed with confidence from the amazing OB, we got engaged and skipped birth control.  I got pregnant on the first try.

During pregnancy, I was able to taper down to just over half my normal medication dose.  It darn near killed me, but I did it.  Then I had to deliver three weeks early because my baby was measuring small, which might have been drug-related and might have just been his genes – we’ll probably never know.  After my son was born I had to adjust back up to my normal level, so breastfeeding was not an option.  I never even considered it.

My son had one sign of neonatal abstinence syndrome: he had a little diarrhea the first few days, but he was breathing and eating well, never developed other symptoms, and never had to go to the NICU for extra treatment.  This is the last thing you might expect to hear from a woman with a C-section scar, but his birth went as well as we could have dared to hope for.

His pediatrician says there are no controlled studies on exposure to this particular medication.  The anecdotal literature suggests a slightly higher risk of dyslexia and learning disability.  If our son turns out to have a learning disability, we’ll handle that as it comes, like any parents would.  I’ve seen students with learning disabilities graduate from college, maybe even some whose mothers had risk factors before they were born.

Don’t get me wrong, I’m right there with the lactivists in condemning corporations marketing formula over breastfeeding, especially in developing countries where water quality is iffy.  Especially when they could have spent those millions of marketing dollars on donations that actually feed starving people.  At the same time, I will always be thankful that formula is readily available.  If formula were outlawed or locked away by a well-intentioned but inflexible “breast is best” initiative, I would never have attempted pregnancy in the first place.  My son – with his curls and big saucer eyes, his sneaky attempts to escape through the doggie door, his personality quirks, his squeaks of excitement when he learns he can pull himself up on the furniture – would never have existed.

We humans need rules to make sense of the world.  We want to nail down moral absolutes – breast is always best, prenatal drug exposure is always unforgivable.

But when I read that first comment on Suzanne Barston’s contact page, when I read “If a mom isn’t willing to do the best possible thing for her baby, then why even have a baby”… I realized, I can’t combat that kind of ignorance with a post on the internet.  This post isn’t even my real argument.

My real argument is my son’s life, as he grows up and makes his way in the world, and maybe even makes the world a better place because he was in it.

***

Feel like sharing your story? Email me at formulafeeders@gmail.com.

 

FFF Friday: “Formula is fun”

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 feelings, and I hope we can all give them the space to do so. 

 

I think Amanda Koppelman-Milstein, the author of the following post, should make a video of her “Formula is Fun” song and put it on YouTube. 

Just sayin’.

Happy Friday, fearless ones (and for once, you might actually feel happy after reading an FFF Friday rather than wanting to stick your head in the oven, thanks to Amanda’s awesome sense of humor),

The FFF

***

 Formula is Fun

by Amanda Koppelman-Milstein

When it turned out I could not exclusively breastfeed, I felt that I needed to launch a mini-publicity campaign for my son so that he would appreciate the benefits of formula. No sucking on manure-contaminated goat’s teats, being farmed out to wet-nurses, or starving to death for my baby—formula exists! We live in a community saturated with breast-is-best messages, and I didn’t want him to feel inferior. In addition, I wanted to cheer myself up in the face of well-meaning advice about increasing my milk supply that made me sob uncontrollably. As I prepared the bottle of formula for my baby’s three AM feeding, I sang my son one of the pro-formula songs I wrote for him:

Breast is best but formula is fun!

Breast is best but formula is fun!

Formula is made by giant evil corporations

But without the formula, you would face starvation.

I had always imagined myself breastfeeding my kids for years, giving them all possible benefits they could obtain from breast milk regardless of the costs to modesty or sanity. Unsurprisingly, I had never dreamed of singing “Yakety Yak (Similac)” while cleaning bottles and praying for a bigger milk supply. However, when I got ulcerative colitis in my second trimester of pregnancy, it became clear that at some point, post-birth, that I was going to want to take some drugs that neither I nor my doctor thought were compatible with breastfeeding. I thought I’d try and get a few months or weeks in of exclusive breastfeeding in before what I referred to as “bringing in the good drugs,” but it turned out I made next to no milk.

In the weeks after he was born, my dedicated son nursed for up to twenty hours a day. My husband held him to my body as I attempted to sleep. After five consecutive hours of nursing, he was still rocking his head back and forth and screaming in hunger. My mother, who was staying with us, announced that this was actually not how breastfeeding was supposed to go, and called in a lactation consultant who arrived the same day our pediatrician said it was time to start supplementing with formula. The lactation consultant mixed him his first bottle, and told us our first priority should be getting our kid fed, and that I had many risk factors for not making enough milk.

We decided to partially breastfeed and hold off on my treating my colitis properly for a few months. Waiting wasn’t a brilliant decision in terms of my own health, but I found breastfeeding addictive. It made the baby so happy! It was so snuggly!  It made him stop crying! It made him go to sleep! It was magic.

Not being able to breastfeed him fully made me feel inadequate. My husband grew entirely bored with the nights when I sat around pumping and crying, saying “We are so fortunate that we have a healthy child (sob). I am so grateful that he is so wonderful and that you are so wonderful, I just wish we didn’t also have to use (sob) formula.”

“WAHHH!” added the baby,cheerfully sucking on whatever was presented to him.

While breastfeeding is magic, formula has a certain amount of magic to it as well. There is a reason public health campaigns need to push breastfeeding in a way they don’t need to push activities that are more compatible with working, sleeping, eating, or running to the subway. Formula is, to some extent, fun. You can give it to the baby anywhere without taking your boobs out, which is endlessly convenient at funerals, police stations, and other places where wearing a shirt is just objectively better. 

I didn’t think I was the sort of feminist who thought formula feeding was good for feminism–I always thought that was an extremist point of view that disregarded the health of infants–until I experience the joy of my husband being responsible for half of the night feedings, and saw what being just as good of a food source as I was did for his relationship with our son. This is not to say I don’t support breastfeeding–just that since I couldn’t, I was able to appreciate the upsides.

Eventually, I hit the illness wall and had to start weaning the baby, which he was extremely gracious about. By this point his appetite massively exceeded whatever milk I could make, and he grinned and bounced a bit when I unlatched him to give him the bottle.

His positive attitude about weaning dissipated when we ran out of the milk I had pumped and frozen before starting with my new medicine. The mainstay of his diet is a vile tasting hypoallergenic formula that turned him from a colicky grump into the happiest and most gregarious baby I have ever met. It smells like rancid mac and cheese. Once that was the only thing going into him, he began inspecting visiting females for signs of lactation, and in a moment of misplaced hope, gave my father-in-law a hickey on his arm. Even once we introduced solids, he pulled down the shirts of visiting females and looked at them as if to say, “Please, would you consider being my wet-nurse? I know this is a sensitive issue for my mom,but we could keep it just between the two of us… Have you seen this soy-free lactose-free stuff they’re giving me? Did you know breast milk is best for young babies, such as myself? Wanna give it a go?”

Due to my months of sadness about only partially breastfeeding, I am more than a little defensive about my “choice”—although I don’t really consider not trying to treat my illness in the long term or letting the kid starve to have been reasonable options. The other week a houseguest made a relatively innocent remark (“At least you got to give him colostrum”) and I ran to the other room to cry. 

Writing this now, when my son is the happiest baby to ever exist, it’s hard to channel the incredible sadness I felt when I couldn’t make enough milk and when I weaned him.  However, recently my doctor suggested switching my medicines, with perhaps a short hiatus between drug-that-has-not-been-shown-to-be-safe and drug-that-you-wouldn’t-breastfeed-on-unless-you-truly-were-insane. “I had a drop of milk come out the other day—maybe I could pump for like two days straight and then breastfeed him for a week or two and then wean him again…” I said to my husband, the days of sobbing while pumping nearly forgotten. However, after I thought about it, it seemed like instead of two straight days of pumping, or whatever it would take to restart the milk supply of someone who has done nothing milk-related for months, my time is perhaps better spent playing peek-a-boo. Formula isn’t the only thing that is fun.

Bad medicine: Why the AAP’s new statement on breastfeeding & medication is puzzling

“The benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk. Although most drugs and therapeutic agents do not pose a risk to the mother or nursing infant, careful consideration of the in- dividual risk/benefit ratio is necessary for certain agents, particularly those that are concentrated in human milk or result in exposures in the infant that may be clinically significant on the basis of relative infant dose or detect- able serum concentrations. Caution is also advised for drugs and agents with unproven benefits, with long half-lives that may lead to drug accumulation, or with known toxicity to the mother or infant. In addition, specific infants may be more vulnerable to adverse events because of immature organ function (eg, preterm infants or neonates) or underlying medical conditions.”

 

- Source: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics Hari Cheryl Sachs and COMMITTEE ON DRUGS. Pediatrics; originally published online August 26, 2013; DOI: 10.1542/peds.2013-1985

The preceding is the conclusion to a new report released by the American Academy of Pediatrics, which has given birth to a number of ecstatic headlines – “Most medications safe for breastfeeding moms”. “Medications of nursing mothers do not harm babies”. “Top Pediatrician’s Group Assures Most Drugs Safe While Breastfeeding”. Reading these, one might assume that a plethora of new research had been released, provoking the AAP to make a blanket statement about risk and benefits.

One should read the actual report before one gets too excited.

Other than the introduction and conclusion, which basically explain that studies are limited on most medications and how they affect a nursing infant, but that the benefits of breastfeeding outweigh the risks, the report reads like one giant warning.

Let’s start with antidepressants:

“Previous statements from the AAP categorized the effect of psychoactive drugs on the nursing infant as “unknown but may be of concern.” Although new data have been published since 2001, information on the long-term effects of these compounds is still limited. Most publications regarding psychoactive drugs describe the pharmacokinetics in small numbers of lactating women with short-term observational studies of their infants. In addition, interpretation of the effects on the infant from the small number of longer-term studies is confounded by prenatal treatment or exposure to multiple therapies. For these reasons, the long-term effect on the developing infant is still largely unknown…Because of the long half-life of some of these compounds and/or their metabolites, coupled with an infant’s immature hepatic and renal function, nursing infants may have measurable amounts of the drug or its metabolites in plasma and potentially in neural tissue. Infant plasma concentrations that exceed 10% of therapeutic maternal plasma concentrations have been reported for a number of selective serotonin reuptake inhibitors…”

As stated in the first sentence of this section, the evidence hasn’t really changed from when the last AAP statement on drugs and human milk was released, circa 2001. But the conclusion sure has. In 2001, the authors advised that “(n)ursing mothers should be informed that if they take one of these drugs, the infant will be exposed to it. Because these drugs affect neurotransmitter function in the developing central nervous system, it may not be possible to predict long-term neurodevelopmental effects.” In 2013, the author states “Mothers who desire to breastfeed their infant(s) while taking these agents should be counseled about the benefits of breastfeeding as well as the potential risk that the infant may be exposed to clinically significant levels and that the long-term effects of this exposure are unknown.”(p. e799)

This is where I start getting nervous. The last thing I ever want to do is discourage someone who needs antidepressants or another lifesaving medication from breastfeeding – especially considering I personally chose to take the small risk and feed my newborn breastmilk while I was on Zoloft (one of the many SSRIs that are categorized in both reports as “Psychoactive Drugs With Infant Serum Concentrations Exceeding 10% of Maternal Plasma Concentrations”, meaning that the levels of the drug getting into a newborn via breastmilk are clinically significant and of potential concern for a growing neonate). These are the risk/benefit scenarios we often discuss here on FFF – decisions that parents need to make (and deserve to make), armed with solid information and free from paternalistic admonishments that don’t have real world meaning. But I don’t feel that the new AAP statement – or the way that the media is reporting it – is allowing for a truly informed decision.

Notice the emphasis of the newer AAP statement – the advice given is to counsel the mother on the benefits of breastfeeding first, and then inform her of the potential risks and unknowns of nursing on her medication. Anyone with a grade-school understanding of psychology can figure out what that would sound like. (“Breastfeeding is extremely important and will save your child from every ill imaginable! But I should warn you that if you choose to nurse while on Zoloft, we can’t confirm or deny that your baby may turn into a werewolf when he reaches puberty. Your choice!”)

Maybe I’m arguing semantics here, but why couldn’t they avoid the paternalism of both the 2001 and the 2013 statement and simply advise doctors to inform parents of the risks and benefits of both feeding options, as well as the risks of nursing on medications, in an accessible, understandable way? And then help them mitigate the risks, no matter what path they choose?

Moving on… painkillers. The AAP is now agreeing with what I freaked out about in Bottled Up – Vicodin and newly postpartum, breastfeeding women are not a match made in heaven. And before you post-C-section mamas beg for the Darvocet, that won’t fly, either. Turns out that infants whose mothers used these commonly prescribed drugs  for managing postpartum pain have popped up with cases of unexplained apnea, bradycardia, cyanosis, sedation, and hypotonia; one infant died from a Vicodin overdose after ingesting the drug through mother’s milk. But hey- you can take (moderate) doses of Tylenol and Advil to manage that post-surgical pain, so no worries.

Are you starting to see why “Medications of nursing moms do not harm babies” might not be the most accurate headline?

Ummm…. Herbal remedies! Those have to be okay, right? They’re natural, after all!

Not so fast, sugar.

“Despite the frequent use of herbal products in breastfeeding women (up to 43% of lactating mothers in a 2004 survey), reliable information on the safety of many herbal products is lacking…The use of several herbal products may be harmful, including kava and yohimbe. For example, the FDA has issued a warning that links kava supplementation to severe liver damage. Breastfeeding mothers should not use yohimbe because of reports of associated fatalities in children…Safety data are lacking for many herbs commonly used during breastfeeding, such as chamomile,black cohosh, blue cohosh, chastetree, echina- cea, ginseng, gingko, Hypericum (St John’s wort), and valerian. Adverse events have been reported in both breastfeeding infants and mothers. For example, St John’s wort may cause colic, drowsiness, or lethargy in the breastfed infant…Prolonged use of fenugreek may require monitoring of coagulation status and serum glucose concentrations. For these reasons, these aforementioned herbal products are not recommended for use by nursing women.”

Wait. It gets worse. You know those galactagogues you were prescribed to increase your milk supply? Flush them down the toilet, says the AAP. The safety of Domperidone, for example, “has not been established.”

“The FDA issued a warning in June 2004 regarding use of domperidone in breast- feeding women because of safety concerns based on published reports of arrhythmia, cardiac arrest, and sudden death associated with intravenous therapy. Furthermore, treatment with oral domperidone is associated with QT prolongation in children and infants.”

The authors aren’t overly enthusiastic about other galactagogues, either, and instead encourage moms struggling with supply to “use non-pharmacologic measures to increase milk supply, such as ensuring proper technique, using massage therapy, increasing the frequency of milk expression, prolonging the duration of pumping, and maximizing emotional support.”

I’ve read the report 10 times now, trying to see where they could possibly come to the conclusion that this is a game changer; that it is at all newsworthy; that this is what counts as progress. To my untrained eye, it appears to be little more than a re-framing of old information to fit in better with the “breast is best at all costs” mantra, rather than a landmark “update” of an antiquated policy paper. Based on this report, how are pediatricians supposed to tell patients, in good conscience, that there is adequate evidence that it’s safe to breastfeed on “nearly all” medications?

For most of the meds in question, it probably is safe- similarly to how the risks of infant formula are scary on paper and far less daunting in real life, I honestly believe that we’d be seeing a lot of seriously messed-up kids if your absolute risk of nursing while on antidepressants was high. Just like many of us have made carefully weighed decisions to formula feed, feeling the weight of misery in one hand and balancing that with an increased risk of ear infections in the other, so shall we handle questions of breastfeeding and medications. The problem is not with moms making choices based on the facts we have- the problem is when respected, policy-creating organizations create false narratives that render us unable to make those choices in a truly informed way.

The report leans heavily on the work of Thomas Hale and LactMed, fantastic resources for research on these issues. I’m grateful there are people dedicated to focusing on this research – research that matters so much more than yet another associative study attempting to show that breastfed babies are smarter than formula fed ones. We desperately need more research on how commonly prescribed medications affect breastfeeding infants, not so that we can “forbid” women from breastfeeding, but so that we can help them reach their breastfeeding goals. This might mean timing medications so that they are mostly metabolized prior to nursing, or pumping for some feeds, or even -god forbid- using a little formula or donor milk for the feeds that have a higher amount of the drug coming through milk (these are tough things to figure out, sometimes, as people metabolize differently, as do babies, but it’s a good goal to have on the horizon). Maybe it means finding better medications. Or it might just mean allowing parents to ponder their own risk/benefit scenarios and respecting their decisions, whatever those may be.

Before we can do that, though, someone has to remind the AAP that they are doctors first, breastfeeding advocates second. Let the science speak, not the zealotry, and maybe we can start helping parents make truly “informed” choices.

 

FFF Friday: “I wonder how many other mentally ill mamas fall through the cracks…”

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 feelings, and I hope we can all give them the space to do so.

This week’s story addresses something that is often ignored or dismissed in conversations about choosing whether of not to breastfeed: mental illness. For someone who struggles with any number of psychiatric disorders, pregnancy and lactation, with all the hormonal and emotional upheaval they bring, can be downright toxic. Or, as Caitlin puts it, a “living hell”. Making the choice to formula feed can be a matter of survival; while some medications are compatible with breastfeeding, others aren’t – and it’s overly simplistic to tell women (as many popular breastfeeding resources do) that “if your medicine is contraindicated, you should probably be able to find one that isn’t”. Treating psychiatric conditions medically often requires “cocktails” of drugs; it can take years to find the right meds, the right doses, and the right combination. We can’t allow the rhetoric to drown out the voices of women who are struggling, and who are trying to tell health care providers (and other members of the peanut gallery) that breast simply isn’t best for them or their babies.

And I won’t even start in on the lack of education and assistance Caitlin was given, because it may well drive me to drink. I’m already *this* close to cracking open a bottle of wine and I still have three hours of “day job” work to do, so that will end badly for everyone. I think Caitlin’s story does an excellent job of making the point I’d want to make, anyway, so I’ll let her go to it.

Happy Friday, fearless ones,

The FFF

***

Caitlin’s Story

I wanted to share my story – the story of someone who knew from the very beginning of her pregnancy that she would not be able to breastfeed her child.

To say that psychiatric problems have plagued me my entire life would not be far off course – I was diagnosed with bi-polar disorder at the onset of puberty at the tender age of eight. It was a long, hard struggle for me and my care providers to find just the right medications that would work for that, along with my anxiety disorder and my later-acquired post-traumatic stress disorder.

When I found out I was pregnant, that carefully-sought combination of medications had to stop. The psychiatric medications that were safe for pregnancy – and subsequently breastfeeding – would not work on their own without careful balancing by other non-baby-safe medications. In fact, they make my issues worse.

So I knew I was in for a rough haul, but never expected my nine months of pregnancy to be a living hell with daily battles against suicidal ideations. That said, my care providers knew from the beginning that it was of paramount importance that I start my medications, as one doctor put it, “as soon as the placenta hit the bucket.”

Despite the fact that it was well-known I would not be able to breastfeed my child, I was given no support or education on how to properly formula feed her. I was met with comments ranging from pity – “It’s a shame you won’t be able to breastfeed. You’ll miss out on some important bonding” – to outright derision, with one nurse even outraged that I would dare put my “imaginary” mental health problems above the well-being of my child.

At the time, I was too tired and too miserable and too out of my right state of mind to be outraged. Every time I think back on those moments, my blood boils. My care providers KNEW for nine months that I would be unable to formula feed. I spent several days in the hospital (courtesy of a crash C-section) wherein I was given no advice on how to feed anything other than the pre-packaged, already mixed formula that came, at great frustration and humiliation, from asking a nurse each time my child was hungry because they would not stock formula in the rooms.

But I endured. And my daughter endured. And everyone who was closely involved with my pregnancy knew that the best thing for my daughter was to have a healthy mother to care for her. So I tried my best to keep my chin up and remember that I was doing what was best for both me AND my daughter.

And lest I be accused of not advocating for myself, every time I asked for guidance or education, I was met with a brush-off, or a “we’ll talk about it later” or even just that withering look that said I was barking up the wrong tree. Or even just a shrug and an “I don’t know what to tell you.”

I was lucky – I had a team of mamas at my disposal who had “been there, done that” with their own children, and their children’s children. They were able to guide me and teach me the ins-and-outs of what to do and what not to do when it came to properly formula feeding my child after we left the hospital.

But sometimes – like now – I wonder how many other mentally ill mamas fall through the cracks, like I almost did? I wonder how many others don’t have that same support network to bolster them and give the education needed to properly formula feed their child? At a time when hormones and serotonin and dopamine are already imbalanced, how many other mentally ill mamas just snapped under the pressure?

I made it through – and almost a year later, my daughter (who is also lactose-intolerant and was fed exclusively soy formula) is thriving and ahead of her development, both mentally and physically. And most importantly, she has a sane mama to help her grow into a wonderful human being.

“Where is the mother in the discussion?” An interview with Walker Karraa on maternal mental health and infant feeding

Some of you may know Walker Karraa from her comments on our Facebook community page, or from her fantastic posts on Science & Sensibility. But I doubt you’re aware of the full magnitude of her bravery and dedication to issues surrounding maternal mental health. I recently interviewed Walker for a short piece on formula feeding and postpartum adjustment, and was so blown away by her answers – I was only able to use a few of her wise words due to word count constraints, so I’m thrilled she’s agreed to let me post the interview in full here on FFF.

Walker is a doctoral candidate at Sofia University, where she is conducting a study on the transformational dimensions of postpartum depression. She was also the founding President of PATTCh, an organization founded by Penny Simkin dedicated to the prevention and treatment of traumatic childbirth, and is a perinatal mental health contributor for Lamaze International’s Science and Sensibility, Giving Birth With Confidence, and the American College of Nurse-Midwives (ACNM) Midwives Connection. Like that wasn’t enough on her plate, Walker also served as social media manager for the Integral Leadership Review, and has her own social media consulting business, On My High Horse, and is currently working toward co-authoring a book regarding PTSD following childbirth with Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA. 

I’m exhausted just reporting all of that. And did I mention she has two kids and is a breast cancer survivor? Yeah, she’s all that and a bag of reduced fat potato chips.

I hope you guys will appreciate the revolutionary nature of Walker’s discussion here – her opinions, while brilliant, probably seem uncontroversial to those who follow this blog, but they are quite “rogue” in the birth/maternal-child health community. I can’t thank her enough for being a dissenting voice and speaking up for the benefit of all women. 

FFF: Here on FFF, we see stories almost weekly which discuss how a perceived “failure” to breastfeed can lead to depression, anxiety, and self-esteem issues. Do you think the maternal mental health community has recognized how breastfeeding (or lack thereof) can affect the emotional state of new moms?

Walker Karraa

WK: I think that overall breastfeeding is very well addressed in the health psychology, and developmental psychology fields. What’s lacking is the reframe of the research to integrate more qualitative data, and methods, into the consideration of the full range of implications of breastfeeding from multiple perspectives—including the woman’s perspective.

In a 1985 Lancet article on maternal mortality, Allen Rosenfield asked the famous question, “Where is the ‘M’ in MCH (Maternal Child Health)? In the discussions of MCH, it is commonly assumed that what is good for the child is good for the mother.” (Rosenfield & Maine, 1985, p. 83). In many ways this is relevant in the discussion of breastfeeding and maternal mental health. Where is the mother in the discussion? And in what ways do we still assume what is good for the child is good for the mother? For me, this is all about reproductive rights and a deeper issue about our discomfort with women’s sovereignty over their reproductive, physical, and mental health.

The mental health community has responded to the growth in published data regarding infant health and breastfeeding. This has also been the funding stream for a large part of the last 20 years. But maternal mental health has yet to directly address a woman’s infant feeding choice as a part of her reproductive choice, rather than discrete periods of time that occur with as a continuum of events that are inextricably woven through reproductive events—none of which, taken by themselves, gives either the best data on mental health.

FFF: What do you feel needs to change in order for new mothers to be better supported in terms of mental health in general?

WK: I think one of the first calls to action must be for maternal care providers to get support in knowing that perinatal mood and anxiety disorders are common and create the conditions for morbidity and mortality for mother and children. This is starting to happen, but still very slow. I think new models of medical care such as Dr. Michael C Lu’s life course model, which places the woman at the center of care, not the doctor. And, she is treated across the lifespan, not merely when she is pregnant. This facilitates better reproductive health in preconception and interconception, and uses a reproductive life plan for women and families from an early age. At puberty, to have a conversation with medical, nutritional, mental health providers as to planning one’s reproduction (girls and boys) would be ideal.

FFF: Many women struggle with the decision of whether to treat postpartum or prenatal depression/anxiety with psycho-pharmaceuticals, especially when they are breastfeeding. Why is there such mixed information and messaging about what drugs are safe, and what the relative risks are (ie, breastfeeding without meds vs breastfeeding on meds vs formula feeding and taking the meds)?

WK: Not having good information is a barrier to care for everyone involved. The OB/GYN or midwife, the social worker, the woman, her partner and family—when we don’t have good information, we cannot make informed choices. And for women in poverty, the risk is twofold. Specifically regarding breastfeeding, but also education across the board regarding psychopharmacology, pregnancy, and lactation. With organizations such as OTIS (Organization of Teratology Information Specialists) and Motherisk, there really is no excuse for not having current evidence-based data regarding risk and benefit of untreated depression and anxiety, as well as risks and benefits of medications used to treat them.

Byatt et al. (2012) did a wonderful grounded theory study regarding community mental health provider reluctance to providing psycho-pharmacotherapy. 28 obstetric care providers (nurses, OB/Gyns, etc.) shared how they perceive community mental health practitioners as obstacles to psychopharmacology for perinatal women. The participants felt community mental health providers “99% of the time” discontinued a patients’ medication, and put women at risk of relapse. Secondly, Byatt et al., (2012) reported that participants perceived a lack of collaboration and communication between community mental health care providers and OB/Gyn providers, and that pharmacists also “further impede or delay depression treatment by not filling needed psychotropic prescriptions, often exacerbating women’s mental health symptoms” (p. 3).

FFF: Why do you think so many women express grief, guilt, and feelings of failure around the subject of infant feeding?

WK: Because that is their experience! And I attribute all of it to social constructs that are completely ingrained in medical, social, and mental health systems that have been made for and by men. The intentions of those men is not necessarily nefarious, and not really the point. It is that the constructs we have to measure ourselves (abilities and weaknesses) are made by men. We tell women from the get-go that they need us to be good mothers. They need our insight, knowledge, treatment, book, video, technique, services, product to be taught how to mother. This is so ironic, because so many of the birth movements have evolved from a call to empower women. But to empower, we have just made more systems of knowledge that mimic the ones we refute. That is not very popular to say, but it is true. The messages still given to women is that if they “know” something analytically, they are devoid of femininity, and if they “know” something inter-subjectively, they are devoid of ration.

Shame is a powerful force for women. And at no time in her life is a woman more susceptible to shame than early motherhood. If they are lucky enough to find a safe space to share their feelings without judgment, such as your blog, they are given the gift of voice. They can speak their truths.

FFF: Any tips for a mom who is having a tough time reconciling her use of formula?

WK: You know, when I was a doula, I had clients ask me to go buy formula for them so they wouldn’t be seen in public. When I was diagnosed with breast cancer shortly after the birth of my second, I underwent two mastectomies before she had turned one. I learned that my body parts have nothing to do with my inherent ability to love her. My breasts were gone—off of my body, one in one hospital and another at a hospital down the road. I fed, nurtured, attached with, loved, and parented without them…and still do! So my advice is to write down on a piece of paper: My breasts have nothing to do with my love for my child. And keep it where you can see it. Memorize it, know it.

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