Monday, 25 August 2014

Why Some Lactation Consultants Fail Breastfeeding Mothers

Lactation Consultants are fairy godmothers devoted to mothers and babies, appearing out of nowhere at the crack of a broken nipple or the click of a bad latch, they sprinkling pixie dust upon mothers' nursing dreams. When they impart their wisdom, their words weave a whimsical spell, furnishing a happily ever after for mom and baby. [Insert the sound of vinyl being scratched].

Back in the real world, lactation consultants, like any professional, are not immune to incompetency. No doubt you’ve heard about LCs dishing out faulty advice to an unsuspecting mother, unwittingly sabotaging her breastfeeding efforts. Perhaps after a poke and a prod they diagnose that a mother's milk has ‘dried up’ when in fact it has just regulated; or perhaps they advocate the breast pump as a gage of how much milk a mother is producing. Maybe they suggest formula top-ups, test weighing, block feeding, controlled crying, et cetera; the list of potentially poisonous advice is endless. Could this explain why for every successful breastfeeding story, there are countless failures? Could some fairy godmothers be witches in disguise? One cannot escape the tragic irony that professionals employed for the sole purpose of facilitating breastfeeding, may actually be partaking in its demise.

Why are so many mothers being sabotaged by lactation consultants? Part of the answer lies in one simple fact:

There are two types of lactation consultant

Before I launch into my rant, I need you to read this short story; its relevance will become apparent, trust me:

After receiving the Nobel Prize for Physics in 1918, Max Planck went on tour across Germany. Wherever he was invited, he delivered the same lecture on new quantum mechanics. Over time, his chauffeur grew to know it by heart: “It has to be boring giving the same speech each time, Professor Planck. How about I do it for you in Munich? You can sit in the front row and wear my chauffeur’s cap. That’d give us both a bit of variety.” Planck liked the idea, so that evening the driver held a long lecture on quantum mechanics in front of a distinguished audience. Later, a physics professor stood up with a question. The driver recoiled: “Never would I have thought that someone from such an advanced city as Munich would ask such a simple question! My chauffeur will answer it!”

Okay, back to breastfeeding. There are two types of knowledge. First, we have real knowledge. We see it in people who have committed a large amount of time and effort to understanding a topic. The second type is what I am going to call chauffeur knowledge - knowledge from people who have learned to put on a show. Maybe they have a white coat, brandish leaflets, even hold a certificate, but the knowledge they espouse is not their own. They are adhering to a scripted 'medical model' of breastfeeding. They reel off eloquent and technical words as if reading from a script. They are on thin ice, and they know it.

The Medical Model of Breastfeeding Advocacy

Unfortunately for the exhausted and, dare I say, vulnerable new mother, it is difficult to distinguish whether a lactation consultant’s advice derives from real knowledge or from medical model - chauffer - knowledge. A major problem with the dominance of the medical model in defining and dealing with breastfeeding problems is that it carries with it implicit assumptions and explicit practices that isolate the innate physiological characteristics of breastfeeding and pathologize them. Normal breastfeeding behaviour is framed as something to be 'worked out' and 'gotten over' like recovery from an acute illness. Yet many breastfeeding 'problems', such as cluster feeding, have no cure, because they are normal healthy biological processes. This situation is exacerbated by the pertinent issue of misdiagnosis.

Let me tell you about a fascinating, if horrific, phenomenon that has been documented in medical research: Patients who are told they have a pathological condition, for instance high blood pressure, immediately begin to experience more illness-related absenteeism from work, though their physiological condition had not changed from previous months or years - they had simply been labelled as sick. Likewise, when mothers are misdiagnosed as having poor milk supply, many behave in a way coherent with this diagnosis, becoming apathetic and debilitated, behaviour which, in turn, leads to genuine low supply. Dayyyyum!

Another problem with the medical model is that it requires the mother to be passive. It assumes an expert professional serving an inexpert patient and thus relies on a hierarchical relationship based on the former's textbook chauffer knowledge. It focuses on atomized mothers and babies, often placing them in a clinical setting, and then separates them from their social, cultural, and historic contexts. When viewed out of context in this way, mothers' social locations and cultural understandings fade out of view. Professionals, placed in the driving seat, draw upon their chauffer knowledge to access and make sense of the symptoms of a passive mother-baby dyad. What I'm saying is that in the medical model, definitions of what constitute a breastfeeding problem flow from the professional's assumptions and stock knowledge and are imposed on the mother and baby's experience rather than being constructed from it.

Indeed, LC's solutions to problems are frequently narrow medical treatments, for instance drug prescriptions, nipple shields, or more commonly, formula top-ups. It continues to astonish me the respect and trust these perfectly-coiffed script readers enjoy, not to mention the fact that they earn a salary delivering support on a topic some of them can barely fathom. Here is some actual advice given by lactation consultants to new mothers (click to read the details in full):

This list is, of course, anecdotal, and thus only scrapes the surface of global maternal experience. It is however clear from such accounts that many LCs are arguably well-intentioned yet ultimately fail because they have only a limited textbook ‘circle of competence’. They rely solely on their chauffeur knowledge. What lies inside this circle they understand; what lies outside, they may only partially comprehend. When faced with an issue outside the perimeters of their competence, say, helping a sick or severely premature baby to latch, they find their script is lacking and so bluff their way through. For instance, the difference between a baby feeding effectively at the breast and one who is struggling to get milk is obvious - if you know what to look for. However, many lactation consultants with chauffer knowledge don't realise that breastfeeding is different from bottle feeding. So, when they see a baby 'sucking strongly' (usually with his lips pursed and cheeks drawn in), they assume he is feeding effectively. They couldn't be more wrong. Unfortunately, because the medical model of breastfeeding is the dominant go-to paradigm, it informs the view of most lay people. Everyday people often join the professional in seeing any hitch in the breastfeeding journey as analogous to an illness.

So, is there still a place for LCs in our health care system? I'd say certainly, but within narrowly prescribed limits. Rather than being insidious witches in disguise, many current LCs are merely out of their depth, often being devoid of the practical acumen that comes with having breastfed a baby oneself. How can mothers distinguish LCs with chauffer knowledge from those with real knowledge? (And more importantly, should mothers be burdened with this task?) A good way for moms to increase their chances of obtaining genuine quality of care, is to opt for the services of a breastfeeding peer supporter (as an extra bonus, they're normally free).

Whilst a LC is apt to apply a fatalistic 'diagnosis' and 'treat' medical-model approach to the breastfeeding journey, a peer supporter - because she has 'been there' herself - is more likely to adopt a practical needs-based 'manage', 'adapt', 'adjust' and 'cope' approach. By the very nature of being a literal peer, she is inclined towards self-empowerment: a non-hierarchal shift from the medical model of 'power over the mother' to having 'power with the mother'. In a nutshell, what I'm advocating here is mothers working with mothers. The Experienced guiding the Novice. In turn, the Novice herself becomes experienced, and passes that wisdom down to another Novice. This is oldschool stuff my friends, and it works.

...And, while you're chewing that over, all this begs the question: Should Breastfeeding Support Workers Have Successfully Breastfed Themselves?

That's a whole other post!

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Lucy said...

In fact, lactation consulting is a fairly new profession which seeks to distance itself from the medical model. That is why IBCLC's must re-certify every 5 years to make sure that their knowledge is current and they keep up with the current research. Also, a good LC seeks to empower the mother and not take over as "the medical expert". If an IBCLC can't tell if a baby is struggling to get milk then seriously something is wrong. This is the basis of what we do everyday...teach mothers to put their babies to breast in such a way that they can drink well which is usually the problem by the way...the baby is put to breast at an awkward angle, with a poor latch and therefore cannot get a good flow of milk going and the mom doesn't realize that the baby isn't getting much.. It takes many many years to become a good LC. You are constantly learning because each mother and baby dyad is unique. It involves constant study and observation to hone your skills and like any profession there are going to be people that are more committed to the cause than others. I've found for the most part, that the science of breastfeeding although it has something to offer is severely limited especially by the language that we use to describe it. Babies have so much to teach us .. they really are amazing and their behaviour is extremely complex. The problem is most people do not take enough time assessing and observing and want to jump right in with their pre-fab opinions and solutions. How much fun it that? Most of what I learned as an LC was through observation and my own "research". To be a good LC you have to take the curriculum with a grain of salt and embark on a lifelong journey of discovery..Breastfeeding is truly an art as is Lactation Consulting.

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