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13th Breastfeeding and Feminism International Conference: The Dance of Nurture in a Complex World: How Biology, Gender, and Social Context Shape How We Nourish Our Children

  • Oman College of Health Sciences

Abstract and Figures

The Breastfeeding and Feminism International Conference (BFIC) is the only global conference that focuses on the sociocultural, economic, health, and political impacts on and of women's infant feeding decisions. We seek to engage a diverse audience in timely conversations to stimulate critical actions and research. To that end, BFIC annually brings together top researchers and policy makers with on-the-ground practitioners in policy, programs, mother-to-mother support, advocacy, communications, and the arts. At the 13th BFIC, we focused on how our everyday infant and child feeding and nurturing activities are shaped by gender, customs, the sociopolitical environment, and how the body and culture relate; breastfeeding, chestfeeding, human milk expression, and sharing are all activities that expand the diversity of infant feeding practices seen around the world. These practices carry multiple meanings across context, entailing different negotiations and compromises. Some are challenged by breastfeeding in a context shaped by systems of gender inequality that ignore the complexity of embodied, gendered nurture. Some experience challenges related to negotiating feeding and nurturing in a context of systemic racism, homophobia, classism, ableism, and other forms of oppression, prejudice , and discrimination. Penny Van Esterik, a truly groundbreaking mother in our field, opened the conference with her address on how "dance" serves as a metaphor for how we nurture, interact, relate, and connect with each other. Members of the National Association of Professional and Peer Lactation Supporters of Color and SisterSong led us in an exploration of how racism and oppression continue to shape infant feeding and parenting practices in the African American community. Trevor MacDonald, whose experiences birthing and chestfeeding two children as a transgender man, helped us learn more about nursing in a context that is both biologically and socially challenging. Dixie Weber, administrator for Women's and Urology, St. Luke's Medical Center in Boise, Idaho, shared a strategy for developing health services that are welcoming for diverse families. Jennifer Yourkavitch, with IFC International, and Aunchalee Palmquist, with the Carolina Global Breastfeeding Institute (CGBI), described the challenges and pleasures of pumping and human milk sharing. CGBI also shared current projects to move the needle in breastfeeding-friendly health care and in improving equity in the lactation profession. We were joined by artists, who helped us see with a different side of our brain: Swedish 6646J HLXXX10.1177/0890334418776646Journal of Human Lactation2018 BFIC Abstracts Additionally, we engaged in conversations on topics that over 60 others brought to the table. These allowed us to further explore how biology, gender, and social context shape the myriad of ways we nurture and nourish infants and young children and how we might improve our work to be inclusive of this rich diversity. We were fortunate to have contributors from Australia, Abstract Background: Changes in patients' demographics around the globe underscore the importance of conducting research that addresses the health care needs of these diverse populations. While valid and reliable measurements in the English language exist, there are challenges to use of these measurements in non-English speaking samples, due not only to language comprehension but also cross-cultural adaptation of some measurement components. Purpose: To create an Arabic translation of the Breastfeeding Attrition Prediction Tool (BAPT). Narrative: This presentation presented the systematic translation and linguistic validation processes of the revised BAPT from English into Arabic. The tool uses a Likert-scale format and is based on the theory of planned behavior, which addresses attitudes, subjective norms, and perceived behavioral control and predicts an individual's intention to engage in a behavior. We discuss the content validity index (CVI) results, which measure the semantic equivalency and cultural adaptability of the translated tool. The cross-cultural validation processes we used were adapted from the Mapi Research Institute's (2002) methodology. The process included (a) forward translation by two bilingual translators, (b) a back translation of the Arabic BAPT into English conducted by an independent translator, (c) expert evaluation using CVI with 10 experts to examine the semantic equiva-lency and cultural relevancy of the translated tool, (d) cogni-tive interviews with 5 Omani women to assess the clarity of the translation, and (e) pilot testing of the translated tool in a convenient sample of 30 Omani postpartum mothers to produce the final version. Conclusions: The cross-cultural adaptation process resulted in item-CVI scores ranging from .8 to 1.00 and a scale-CVI of .95. The cognitive interviews helped identify items that required modifications before the pilot test. The pilot test resulted in Cronbach's alphas for the subscales ranging from .31 to .93. The semantic equivalency results provided additional confirmation of the appropriateness of the translated tool by experts and the use of the items in everyday Omani language. The cross-cultural adaptation process helped to verify the accuracy of the translated tool and the adaptability of the tool itself to Arabic culture. Background: Researchers have consistently demonstrated that black infants are less likely to initiate and continue breastfeeding than white or Hispanic infants in the United States. However, it is unclear how these racial/ethnic disparities are associated with other sociodemographic factors such as income.
Content may be subject to copyright.
Journal of Human Lactation
2018, Vol. 34(3) 600 –630
© The Author(s) 2018
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DOI: 10.1177/0890334418776646
BFIC Abstracts
March 21-23, 2018, Sheraton Hotel, Chapel Hill, North
Carolina USA
Facebook: Breastfeeding and Feminism International
The Breastfeeding and Feminism International Conference
(BFIC) is the only global conference that focuses on the
sociocultural, economic, health, and political impacts on
and of women’s infant feeding decisions. We seek to
engage a diverse audience in timely conversations to stim-
ulate critical actions and research. To that end, BFIC
annually brings together top researchers and policy mak-
ers with on-the-ground practitioners in policy, programs,
mother-to-mother support, advocacy, communications,
and the arts.
At the 13th BFIC, we focused on how our everyday infant
and child feeding and nurturing activities are shaped by
gender, customs, the sociopolitical environment, and how
the body and culture relate; breastfeeding, chestfeeding,
human milk expression, and sharing are all activities that
expand the diversity of infant feeding practices seen
around the world. These practices carry multiple mean-
ings across context, entailing different negotiations and
compromises. Some are challenged by breastfeeding in a
context shaped by systems of gender inequality that ignore
the complexity of embodied, gendered nurture. Some
experience challenges related to negotiating feeding and
nurturing in a context of systemic racism, homophobia,
classism, ableism, and other forms of oppression, preju-
dice, and discrimination.
Penny Van Esterik, a truly groundbreaking mother in our
field, opened the conference with her address on how “dance”
serves as a metaphor for how we nurture, interact, relate, and
connect with each other. Members of the National Association
of Professional and Peer Lactation Supporters of Color and
SisterSong led us in an exploration of how racism and
oppression continue to shape infant feeding and parenting
practices in the African American community. Trevor
MacDonald, whose experiences birthing and chestfeeding
two children as a transgender man, helped us learn more
about nursing in a context that is both biologically and
socially challenging. Dixie Weber, administrator for
Women’s and Urology, St. Luke’s Medical Center in Boise,
Idaho, shared a strategy for developing health services that
are welcoming for diverse families. Jennifer Yourkavitch,
with IFC International, and Aunchalee Palmquist, with the
Carolina Global Breastfeeding Institute (CGBI), described
the challenges and pleasures of pumping and human milk
sharing. CGBI also shared current projects to move the nee-
dle in breastfeeding-friendly health care and in improving
equity in the lactation profession. We were joined by artists,
who helped us see with a different side of our brain: Swedish
776646JHLXXX10.1177/0890334418776646Journal of Human Lactation2018 BFIC Abstracts
13th Breastfeeding and Feminism
International Conference: The Dance
of Nurture in a Complex World: How
Biology, Gender, and Social Context
Shape How We Nourish Our Children
Paige Hall Smith
Center for Women’s Health and Wellness
Professor, Public Health Education
School of Health and Human Sciences
University of North Carolina at Greensboro
Catherine Sullivan
Director and Assistant Professor
Carolina Global Breastfeeding Institute
Department of Maternal and Child Health
Gillings Global School of Public Health
University of North Carolina at Chapel Hill
BFIC Abstracts 601
photographer Elizabeth Ubbe, filmmaker Elizabeth Bayne
(Chocolate Milk), and film producers Chantal Molnar and
Jennifer Davidson (The Milky Way).
Additionally, we engaged in conversations on topics that
over 60 others brought to the table. These allowed us to
further explore how biology, gender, and social context
shape the myriad of ways we nurture and nourish infants
and young children and how we might improve our work to
be inclusive of this rich diversity. We were fortunate to
have contributors from Australia, Canada, Ghana,
Guatemala, Indonesia, New Zealand, Nigeria, Poland,
Puerto Rico, South Africa, Sweden, Switzerland, the United
Kingdom, and the United States.
The Center for Women’s Health and Wellness at UNC
Greensboro and the Carolina Global Breastfeeding Institute
at UNC Chapel Hill extend our heartfelt thanks to the 208
attendees and 70+ presenters who engaged in crucial—
sometimes difficult, other times controversial, always
Arabic Translation and Linguistic
Validation of the Revised Breastfeeding
Attrition Prediction Tool
Al-Barwani, S. S., PhD,1,2 Hodges, E. A.,1 Sullivan, C.,3
Thoyre, S. M.,1 Knafl, K. A.,1 & Crandell, J. L.1
1School of Nursing, University of North Carolina-Chapel
Hill; 2Ministry of Health, Muscat, Oman; 3Carolina Global
Breastfeeding Institute, University of North Carolina-Chapel
Hill, North Carolina, USA
Background: Changes in patients’ demographics around
the globe underscore the importance of conducting research
that addresses the health care needs of these diverse popula-
tions. While valid and reliable measurements in the English
language exist, there are challenges to use of these measure-
ments in non–English speaking samples, due not only to lan-
guage comprehension but also cross-cultural adaptation of
some measurement components.
Purpose: To create an Arabic translation of the Breastfeeding
Attrition Prediction Tool (BAPT).
Narrative: This presentation presented the systematic
translation and linguistic validation processes of the revised
BAPT from English into Arabic. The tool uses a Likert-scale
format and is based on the theory of planned behavior,
which addresses attitudes, subjective norms, and perceived
behavioral control and predicts an individual’s intention to
engage in a behavior. We discuss the content validity index
(CVI) results, which measure the semantic equivalency and
cultural adaptability of the translated tool. The cross-cul-
tural validation processes we used were adapted from the
Mapi Research Institute’s (2002) methodology. The process
included (a) forward translation by two bilingual translators,
(b) a back translation of the Arabic BAPT into English con-
ducted by an independent translator, (c) expert evaluation
using CVI with 10 experts to examine the semantic equiva-
lency and cultural relevancy of the translated tool, (d) cogni-
tive interviews with 5 Omani women to assess the clarity of
the translation, and (e) pilot testing of the translated tool in
a convenient sample of 30 Omani postpartum mothers to
produce the final version.
Conclusions: The cross-cultural adaptation process resulted
in item-CVI scores ranging from .8 to 1.00 and a scale-CVI
of .95. The cognitive interviews helped identify items that
required modifications before the pilot test. The pilot test
resulted in Cronbach’s alphas for the subscales ranging from
.31 to .93. The semantic equivalency results provided addi-
tional confirmation of the appropriateness of the translated
tool by experts and the use of the items in everyday Omani
language. The cross-cultural adaptation process helped to
verify the accuracy of the translated tool and the adaptability
of the tool itself to Arabic culture.
Racial and Ethnic Disparities in
Breastfeeding by Household Income in
the United States, 2013 Births
Anstey, E. H., PhD, Li, R., Chen, J., & Perrine, C. G.
Centers for Disease Control and Prevention (CDC), Atlanta,
Georgia, USA,
Background: Researchers have consistently demonstrated
that black infants are less likely to initiate and continue
breastfeeding than white or Hispanic infants in the United
States. However, it is unclear how these racial/ethnic dispari-
ties are associated with other sociodemographic factors such
as income.
Purpose: The purpose of this study was to examine how
racial/ethnic disparities in breastfeeding vary by income
level for breastfeeding initiation, exclusive breastfeeding at 6
months, and breastfeeding at 12 months.
Narrative: We analyzed National Immunization Survey data
for children born in 2013 (survey years 2014-2016). Because
of potential interactions between demographics and race/eth-
nicity, breastfeeding data were stratified by both race/ethnic-
ity and the poverty income ratio to examine factors associated
with breastfeeding outcomes. Overall, black infants had sta-
tistically significantly lower rates of breastfeeding than white
infants across all three indicators: ever breastfed (66.3% vs.
84.3%), exclusive breastfeeding at 6 months (15.4% vs.
602 Journal of Human Lactation 34(3)
27.4%), and breastfeeding at 12 months (20.2% vs. 36.1%).
Hispanic infants had statistically significantly lower rates of
breastfeeding than white infants for exclusive breastfeeding
at 6 months (20.8%) and breastfeeding at 12 months (26.7%)
but not ever breastfeeding (82.9%). Black infants had consis-
tently lower breastfeeding rates than white infants within the
same categorization of income level. For example, the largest
significant difference among whites (92.4%) versus blacks
(73.9%) for ever breastfed was 18.5 percentage points among
families with the highest income level (poverty income ratio
of 600 or greater). Compared to white infants with the lowest
income level (poverty income ratio of less than 100), Hispanic
infants of the same income level had significantly higher rates
of ever breastfeeding (81.5% vs. 70.5%). Among infants with
the highest income level, Hispanic infants had significantly
lower rates of exclusive breastfeeding at 6 months (16.2% vs.
31.5%) compared to white infants. The differentials in breast-
feeding rates between high- and low-income statuses were
most substantial among white infants and black infants for all
indicators, with the higher rates in the higher income level.
For example, among white infants at the highest income level,
92.4% had ever breastfed, compared to 70.5% at the lowest
income level, a difference of about 22 percentage points.
Conclusions: Black infants have consistently lower breast-
feeding rates for initiation, duration, and exclusivity than
white infants with similar income levels. The large differ-
ences in breastfeeding rates among each racial/ethnic group
by income indicate the need for culturally appropriate inter-
ventions, particularly among low-income families. The sig-
nificantly lower rates for breastfeeding exclusivity and
duration among Hispanic infants when compared to white
infants requires further exploration to identify the barriers to
breastfeeding continuation among Hispanic mothers.
Lies and Lactation Cookies: Raising the
Bar for Breastfeeding Support Groups
Barron Smolinski, A.
Mom2Mom Global, Landstuhl, Germany
Background: Millennial parents live and learn on social
media. Yet much of the information available online, even
through lactation “support” groups, is outdated, inaccurate,
and counterproductive. Millennial parents, particularly
mothers, also place pressure on themselves to get parenting
“right,” which leads to a complex and dangerous blend of
anxiety, guilt, and fear surrounding all of their parenting
decisions. Facebook closed groups can be an effective plat-
form for creating a virtual breastfeeding support group, but
just as in real life, the groups must be properly facilitated to
ensure the peer-to-peer education is accurate.
Purpose: Step-by-step guidance to creating, setting up, and
maintaining a Facebook breastfeeding support group, based
on real-world experience of developing best practices used
by Mom2Mom Global, a national nonprofit network of
breastfeeding peer support for military families. Strategies
include identifying common language and terminology used
in Facebook groups, understanding the difference between
harmful conflict and safe conflict, and leveraging social
media to connect with, educate, and support today’s parents
where they are. It is also vitally important for lactation pro-
fessionals to be aware of potential ethical ramifications of
social media interactions and set and maintain clear expecta-
tions and boundaries around their involvement.
Conclusion: By deconstructing common controversies that
occur within social media and analyzing conflict manage-
ment strategies, lactation professionals can create safe spaces
online for parents to receive accurate, evidence-based educa-
tion. When millennial parents feel that a relationship has
been forged and lactation professionals are safe, trusted
information sources, they are more likely to seek out and
trust in-person support and advice.
6 Months Exclusive Breastfeeding:
Socially Constructed Behaviour
Influenced by Social Relationships and
Social Interactions
Benn, C., & Alianmoghaddam, N.
College of Health, Massey University, Palmerston North,
New Zealand
Background: Despite consensus regarding the health ben-
efits of 6 months exclusive breastfeeding (EBF) for mothers
and infants, its prevalence of 6 months EBF is low in devel-
oped countries, including New Zealand. The World Health
Organization has developed one universal set of EBF guide-
lines, however, large differences in EBF rates by country
suggest that the historical, socioeconomic, political, geo-
graphic, and sociocultural contexts of breastfeeding in these
countries may need to be considered.
Purpose: The purpose of this study was to investigate the
factors affecting EBF in a population of women already
motivated to EBF for 6 months.
Narrative: This qualitative study involved face-to-face post-
partum interviews with 30 mothers who prior to the birth of
their infants were characterized as socially advantaged, well
educated, and highly motivated to EBF for 6 months. Social
constructionism was considered as an epistemological frame-
work. The Massey University Human Ethics Committee
approved this research. While having an antenatal intention to
BFIC Abstracts 603
EBF is an important predictor, this intention does not accu-
rately predict EBF at 6 months as there are many factors that
influence this behavior. The extended theory of planned
behavior was applied to demonstrate how self-identity also
plays a significant role in the prediction of a prolonged dura-
tion of EBF. The two components of this theory, subjective
norms and self-identity, emphasize how decision making
around EBF is created through social relationships and social
interaction. There is scant literature about the important time-
frame between 3 and 6 months when the maintenance of EBF
may be challenging for mothers. Most studies have linked bar-
riers to EBF to difficulties within the mother-infant dyad and
the negative maternal socioeconomic and sociodemographic
characteristics. Therefore, one of the strengths of this research
is that the maintenance of 6 months EBF behavior is challeng-
ing and demanding even for the participants who were socially
advantaged, well educated, and highly motivated to EBF for 6
months. Resistance to breastfeeding because of feeling pres-
sured, guilt, and judgments around formula feeding as well as
surveillance or monitoring of the mothers by the health profes-
sionals who are employed by the government is an important
finding. Therefore, Michel Foucault’s theories of governmen-
tality and bio-power were applied for interpreting the findings
of resistance to breastfeeding. However, mothers in this
research appreciated the effective support from the commu-
nity midwives who empowered them to look after their infants
regardless of the method of infant feeding as well as strength-
ened the new mothers’ self-efficacy, respect, and autonomy.
Conclusion: Consideration of the mother-infant dyad as the
main target for promoting 6 months exclusive breastfeeding
has failed to address the low rate of this behavior in devel-
oped countries, including New Zealand. Therefore, the cen-
tral finding of this research is that 6 months EBF is not
limited to the intentions or actions of the mother-infant dyad;
it is socially constructed and influenced by actual and virtual
social networks around the mother as well as the historical,
socioeconomic, political, geographic, and social contexts of
the mother’s life.
“Unbreastfed”: The Far-Reaching
Consequences of Water Insecurity for
Infant Feeding Practices in Low- and
Middle-Income Countries
Butler, M. S.1, Schuster, R. C.2, Collins, S. M.1,3, Young, S. L.1,3,
& HWISE Consortium3
1Department of Anthropology, Northwestern University,
Evanston, IL, USA; 2Center for Global Health, School for
Human Evolution and Social Change, Arizona State University,
Tempe, AZ, USA; 3Household Water Insecurity Experiences
Consortium, Northwestern University, Evanston, IL, USA
Background: Water insecurity is a global issue with
numerous health repercussions. Water insecurity may be
particularly deleterious for maternal and child health, but
its role in infant feeding has largely been overlooked.
Therefore, we investigated the consequences of water inse-
curity for infant feeding, specifically focusing on breast-
feeding practices.
Purpose: This was an exploratory project to better under-
stand the impacts of water insecurity on breastfeeding prac-
tices. We hope this encourages more in-depth investigations
of the relationships between water insecurity and infant feed-
ing practices globally.
Narrative: The Household Water Insecurity Experiences
(HWISE) study is measuring household water insecurity in
26 sites across four continents to develop the first cross-cul-
turally validated water insecurity scale. Here we focused on
3,301 responses from participants in 11 sites to the open-
ended question: “Can you tell me some ways that the water
situation here affects how infants (under 12 months of age)
are fed?” After developing a codebook using inductively and
deductively derived codes, responses were coded using
Dedoose and thematically analyzed. Water insecurity was
perceived to be harmful to breastfeeding and complementary
feeding through five main pathways: economic, nutrition,
hygiene, psychosocial, and societal expectations of maternal
responsibilities. In terms of economic well-being, we found
that water acquisition and treatment take both time and
financial resources away from infant care. Often women are
left with less time to breastfeed or without enough money to
provide nutritionally adequate complementary foods for
infants or food for themselves. As for psychosocial health,
women experience higher levels of stress due to the inability
to provide infants with the care they need, which may nega-
tively impact infant nutrition through decreased human milk
production. In terms of the nutrition and hygiene pathways,
mothers may avoid breastfeeding when they do not have
access to clean water or if they drink unclean water for fear
of transmitting pathogens and bacteria to the infant via
human milk. Women are less likely to drink or cook with
contaminated water, which may be reducing human milk
production. Finally, water acquisition and management are
typically in the realm of “women’s work.” Water insecurity
takes critical time and financial resources away from care-
giving capacities and adds additional physical and mental
burdens, which are exacerbated by societal expectations of
maternal responsibility.
Conclusion: In sum, these data indicate how breastfeeding
and other infant caretaking practices are adversely affected
by a lack of access to regular supply of adequate water.
Future research should ask more specific questions about
604 Journal of Human Lactation 34(3)
infant feeding modalities and quantify the health impacts of
water insecurity in the first 1,000 days.
Swedish Women’s Thoughts About
Breastfeeding During Late Pregnancy
Cato, K.1, Sylvén, S.2, Henriksson, H. W.3, & Rubertsson, C.1
1Department of Women’s and Children’s Health; 2Department
of Neuroscience; 3Department of Gender Studies, Uppsala
University, Uppsala, Sweden
Background: In Sweden, national data sets show that
approximately 15% of children are breastfed exclusively at
the age of 6 months, thus following the recommendation of
both the World Health Organization and the Swedish
National Food Agency. The duration of breastfeeding in
Sweden has decreased over time ever since the 1990s when
it peaked. However, 15% is a rather low figure when data
show that 97% of Swedish women initiate breastfeeding and
most women when asked during late pregnancy declare that
they want to breastfeed. Women’s goals for breastfeeding
often depend on their working situation. In many countries,
parental leave is short or nonexistent, leaving the mother the
options of either staying at home and giving up her job or
planning her method of giving the baby food according to
the possibilities her job gives her. In Sweden, in general
women do not face this issue since the parental leave system
is very generous, granting parents 480 days in total per
child. Statistics from the Swedish Social Insurance Report
show that most parental leave days are spent during the
child’s first two years, and in total, the days are mostly used
by the mothers (76.3%). Hence, issues other than work-
related ones seem to influence Swedish women when it
comes to planning their future breastfeeding as well as their
choice of exclusive breastfeeding, partial breastfeeding, or
not breastfeeding at all.
Purpose: In this qualitative study, we aimed to explore
Swedish women’s thoughts about and plans for breastfeed-
ing during late pregnancy.
Narrative: Using in depth-interviews with women in gesta-
tional weeks 35-37, we allow women to record their own
words about breastfeeding in general and their plans for
breastfeeding and the issues they consider as they form those
plans. The interviews disclose that Swedish women seem to
have a strong motivation to breastfeed according to the WHO
recommendations but also that they worry about the avail-
ability of adequate breastfeeding support. When envisioning
their future breastfeeding, the women made uncertain and
preliminary plans and negotiated benefits and obstacles of
The Journey to Medicaid
Reimbursement of Medical Lactation
Services in North Carolina
Chetwynd, E. M., BSN, IBCLC, MPH
Research Scientist of Clinical Lactation, North Carolina
State University, Pittsboro, NC, USA; Next Level Lactation,
LLC, Pittsboro, NC, USA
Background: Accessible, high-quality lactation support is
pivotal to supporting breastfeeding continuation. In the
United States, our breastfeeding initiation rates are increas-
ing, but the rate of breastfeeding at 3 months, 6 months, and
a year or more are much slower to improve. There are many
reasons women stop breastfeeding, but the most common
causes of early cessation (pain, low breastfeeding self-effi-
cacy, low production) are difficulties that can be successfully
addressed with the support of a knowledgeable health care
Aims/Purpose: The mandates in the Affordable Care Act
that included providing comprehensive lactation support and
counseling to clients without copayment, coinsurance, or a
deductible were meant to increase accessibility to high-qual-
ity support for individuals experiencing breastfeeding diffi-
culties. These policies were included in the rollout of optional
improved coverage of preventive care services under
Medicaid policies. North Carolina was one of the states that
opted out of the increased services and therefore was not
required to cover lactation services. The purpose of this
workshop was to tell the story of the advocates who worked
on this policy, define medical lactation therapy, and discuss
the compromises inherent in the North Carolina process.
Narrative: Despite their grandfathered status, NC DMA
prioritized lactation and created a policy that would cover
International Board-Certified Lactation Consultants
(IBCLCs) as well as physicians and nurse practitioners and
midwives who provide lactation support. This policy was the
result of steady pressure over seven years by an array of
advocates from lactation, primary health care, pediatric
advocacy groups, and legislative committees. Pivotal to the
process was a cost benefit analysis that was presented to the
legislative committee and repeated by NC Medicaid. The
success of the project was dependent on good communica-
tion and creativity. The medical lactation services policy was
finalized in December of 2017, and there are several impor-
tant elements that will be the focus of the statewide rollout.
The policy is primarily structured using incident-to billing,
which requires collaborative practice between physician
offices and IBCLCs; however, billing codes are incorporated
into the language of the policy that allow for increased inde-
pendence within the incident-to collaborative structure. We
BFIC Abstracts 605
anticipate that this collaborative structure will facilitate con-
versations between IBCLCs and established medical care
facilities, potentially increasing the number of IBCLCs
embedded in the health care system. The policy also impor-
tantly defines what is required for a lactation consultation to
be recognized as a reimbursable service, which is an impor-
tant step toward providing a standard of care. The need for
treatment notes to be sent to the primary care provider by the
lactation support provider will increase awareness of the spe-
cifics and importance of lactation care in our state.
Conclusion: This policy is a compromise document that
facilitates reimbursement for lactation consulting while
increasing transparency between this particular insurance
provider and lactation support providers. The incident-to
structure does not allow for home visits or provision of ser-
vices where primary health care is absent, but it will encour-
age hiring IBCLCs to pediatric practices.
The Effects of Peer Support
on Maternal Experiences and
Breastfeeding Outcomes: An
Evaluation of UNC’s M.O.M.
Networking Group
Christy, S. M.
Chapel Hill, NC, USA
Background: The Mentoring Other Mothers (M.O.M.) net-
working group is a free, weekly maternal support group
offered by the Baby-Friendly designated UNC Women’s
Hospital. Hospital staff view the group as a successful tool in
improving breastfeeding outcomes. To date, however, there
has been no formal review of the group. As the demand for
Baby-Friendly accredited facilities and accompanying sup-
port resources increases, examination of established pro-
grams is necessary to provide sustainable models and
demonstrate the need for such resources.
Aims: The aims were to (a) examine the differences in
breastfeeding outcomes between mothers who attended the
M.O.M. group and mothers who received similar prenatal
care and education but did not access postnatal supportive
resources through the hospital, (b) evaluate the M.O.M.
group using the feedback of past participants, and (c) share
the lived experiences of mothers who have received struc-
tured, maternal peer support.
Narrative: An invitation to participate was sent to all moth-
ers who attended the M.O.M. group and/or UNC’s breast-
feeding class during the year 2016. Both groups of
participants were invited to complete an electronic survey.
M.O.M. group participants were invited to partake in an
interview. Current weekly sessions of the M.O.M. group
were observed. Measures of breastfeeding outcomes included
formula use, breastfeeding exclusivity, and breastfeeding
duration. Among M.O.M. participants, 42% (n = 12) reported
formula use. Among breastfeeding class participants, 52% (n
= 30) reported formula use. The mean age at which non-
human milk liquids or solids were introduced among the
M.O.M. participants was 5.03 months, SD = 3.02. Among
breastfeeding class participants, the mean age was 5.04
months, SD = 1.77. The mean reported age at which the
mother stopped feeding the baby human milk among the
M.O.M. participants was 14.22 months, SD = 5.93. Among
breastfeeding class participants, the mean age was 12.37
months, SD = 4.32. M.O.M. participants were asked what
they enjoyed most about attending the group. The most com-
mon themes included socialization and being around others
who were in a similar situation. The most frequent sugges-
tions for improving the group included having alternative
times and locations and advertising the group. The most
common theme that emerged from the interviews with
M.O.M. participants was the value of shared experiences.
Themes of guilt and failure surrounding breastfeeding and
motherhood also emerged.
Conclusions: There were no significant differences between
the breastfeeding outcomes of the two groups. Rates of for-
mula use and reported lengths of breastfeeding exclusivity
and duration reveal that even among populations that have
access to quality education, care, and supportive resources,
meeting best practice breastfeeding goals may be difficult.
Feedback from the M.O.M. participants highlights the neces-
sity of socialization and peer support networks for mothers.
Evaluations of the M.O.M. group demonstrate the need for
sessions to be more conscious of all mothers, namely, work-
ing mothers, those not breastfeeding, and those with multiple
children. Further research should examine the effects of peer
support on breastfeeding outcomes within diverse popula-
tions and population that did not receive prenatal breastfeed-
ing education.
Establishing, Maintaining, Marketing,
and Evaluating a University Lactation
Support Program: A Collaborative and
Inclusive Approach
Clark, A. M.,1 & Lucero-Nguyen, Y.2
1Nutrition and Dietetics Program, 2Women’s Resource
Center, University of Northern Colorado, Greeley, CO, USA
Background: Human milk is the recommended form of
infant nutrition throughout the first year of life and beyond.
A common reason why parents cease breastfeeding/
chestfeeding is because of returning to work or school. In
606 Journal of Human Lactation 34(3)
2008, Colorado passed the Workplace Accommodations for
Nursing Mothers Act, which requires employers to provide
adequate break time and a private place for employees to
express human milk for their child.
Aim: Our project aims to describe the “how-to” of establish-
ing an inclusive lactation support program on university and
college campuses through an intersectional feminist lens.
Narrative: An environmental scan on a Colorado campus
was conducted to determine if there was a location that
would provide parents a comfortable, private, and inclu-
sive space to express human milk. Five Lactation Stations
have been successfully established. A questionnaire on the
effectiveness and usage of the Lactation Stations was
developed and administered. Over 100 women (~1,600
visits) have used the Lactation Stations since 2012. All
parents who filled out the Lactation Stations’ Evaluation
Survey (n = 42) have stated that the Lactation Stations met
their needs and without the space they would not have
breastfed/chestfed their infants past 6 months (average
duration rates are approximately 10 months per the sur-
vey). Continued evaluations and conversations will occur
to ensure that the spaces meet the needs of students, fac-
ulty, staff, and the community. An intersectional feminist
approach was taken in the development of the lactation
support program to support normalizing the diverse narra-
tives that exist with lactating bodies. When establishing
Lactation Stations, access and inclusion are central in
determining what spaces would be optimal. Identities that
lactating individuals have are layered and expand beyond
a cis-woman identity. To normalize narratives around lac-
tation, multiple representations of narrative are shared on
the campus. The “Because lactating looks like this . . . ”
campaign showcases lactating bodies with identity repre-
sentation that spans across race, ethnicity, gender, and
class as well as lactation experiences that include breast-
feeding, chestfeeding, and expressing human milk.
Conclusion: Providing lactation support on university and
college campuses is important. To support other campuses
on the development of lactation support programs, the
Toolkit for Establishing Breastfeeding Support on University
and College Campuses for universities and other organiza-
tions was developed. The toolkit includes a how-to for estab-
lishing lactation support programs as well as an example
policy, lactation accommodation request forms, and recom-
mendations for a collaborative approach.
Racial Equity: A Call to Action
Davis, S., Santaballa, L., & Tatum, M. A.
National Association of Professional and Peer Lactation
Supporters of Color, Detroit, MI, USA
Background: The National Association of Professional and
Peer Lactation Supporters of Color (NAPPLSC) is a U.S.-
based nonprofit organization, founded in 2014 by five
women of color. NAPPLSC’s mission is to cultivate a com-
munity of diverse professional and peer lactation supporters
to transform communities of color through policy, breast-
feeding, and skilled lactation care. As the only organization
of color geared toward lactation support persons and profes-
sionals of color, NAPPLSC has been afforded the opportu-
nity to work with and support communities of color
throughout the nation. NAPPLSC is at the forefront by con-
ducting racial equity trainings for organizations of privilege
and individuals interested in expanding their journey to cul-
tural competence and cultural humility in the effort to reduce
the health disparities, high infant mortality and maternal
morbidity rates, and low breastfeeding outcomes.
Purpose: Race, as we know, is a social construct. There is
no scientific reality to this construct. Race is socially deter-
mined, not biologically determined. The U.S. notion of race
has been around for a little over 300 years. Before that, there
were identity groups based on ethnicity and religion. Ideas of
race, both scientific and cultural, have continued to shift over
time. Our ideas of race come from family, the media, schools,
government, religion, and so on. The number of different
races shifts over time according to what our institutions say.
Although there are negative consequences from racism,
racial categories can also be associated with important cul-
tural values.
Narrative: We live in a highly racial society—specifically,
race matters. We know that some progress has been made
over the years when it comes to racial equity. Yet if you look
at any measure of success (income, education, health, crimi-
nal justice, etc.), significant differences in outcomes based
on race remain deep and pervasive. We’re having this con-
versation because of these inequities, because of our desire
to create equitable outcomes where everyone can succeed.
We are not just talking about individual acts of bigotry; we
are talking about institutions and systems that perpetuate
inequity. We are all a part of institutions and systems.
Sometimes there is a tendency to focus on personal acts of
racism. Instead, we want to focus on the institutions and sys-
tems that continue to impact people based on their race. We
need to analyze why inequities continue to persist and
develop practical changes that result in different outcomes. It
is time that we look at the big picture.
Conclusion: We have a responsibility for advancing racial
equity. None of us asked to be born into a world where race
influences every single indicator for success. Nevertheless,
although we are not responsible for history, we are respon-
sible for what happens today and the future. Racism impacts
all of us, we all have a role to play in ending it. Achieving
health equity through breastfeeding will require an explicit
BFIC Abstracts 607
examination of how institutional and structural racism create
barriers for women of color.
Feasibility and Acceptability of an
Antenatal Milk Expression Protocol
Among First-Time Mothers in the U.S.
Demirci, J. R.1, Fichner, J.1, Glasser, M.1, Caplan, E.1, &
Himes, K.2
1University of Pittsburgh School of Nursing, Department of
Health Promotion & Development; 2Magee-Womens
Research Institute & Department of Obstetrics, Gynecology,
and Reproductive Sciences, Pittsburgh, PA, USA
Funding: American Nurses Foundation ANA Presidential
Scholar Award, University of Pittsburgh Central Research
Development Fund
Background: Antenatal milk expression (AME) involves
maternal hand expression, collection, and storage of milk in
the third trimester of pregnancy. Purported benefits include
immediate availability of banked milk at birth and the capac-
ity to build breastfeeding confidence in a low-stakes, antena-
tal environment. Recent research from the DAME Trial
indicates that AME is not associated with adverse perinatal
outcomes and may increase in-hospital breastfeeding exclu-
sivity. While AME is growing in popularity outside the
United States, its feasibility and acceptability among U.S.
women is unknown.
Aims: To examine uptake of and experiences with AME
among U.S. women expecting their first child.
Narrative: In this ongoing pilot randomized trial, 43
healthy, nulliparous women from a hospital-based midwife
practice were recruited and randomized to receive either an
AME intervention or breastfeeding education handouts. The
AME intervention involved demonstration and practice of
AME with an IBCLC beginning at 37 gestational weeks,
technique reinforcement at weekly study visits until deliv-
ery, and home practice (and logging) of AME one to two
times per day for 10 minutes each. Women who received
AME were invited to participate in a semi-structured inter-
view at one to two weeks postpartum regarding their experi-
ences. Interviews were analyzed for major themes by two
independent coders. Descriptive statistics were used to char-
acterize sample demographics and AME practices. Majority
of participants were non-Hispanic white, married, and col-
lege educated. Mean age was 30.8 years (SD = 3.9). Of 21
women randomized to AME, 17 received the intervention
(at least one study visit) and participated in an interview. Of
these, 14 were able to express any antenatal milk, 9 froze
antenatal milk, and 5 fed antenatal milk to their infant in the
early postpartum period (reasons for antenatal milk use:
maternal-infant separation, perceived inadequate milk, latch
issues, and desire for partner participation in feeding). With
an average of 18.9 home AME sessions, the average volume
of antenatal milk expressed from 37 weeks to delivery was
18.3 mL (range: 0-88.8 mL), with small increases in milk
volume observed in successive weeks (e.g., 0.75 mL/session
in Week 37 to 1.3 mL/session in Week 39). Overwhelmingly,
women had favorable attitudes toward AME. Perceived ben-
efits included opportunities to “practice” milk expression,
handle breasts, and visualize and collect milk; these experi-
ences were perceived to prepare/“toughen” breasts for
breastfeeding and increase breastfeeding commitment, con-
fidence, embodied knowledge, and partner support. Some
women attributed a perceived rapid onset of lactogenesis II
and a plentiful postpartum milk supply to AME. AME con-
cerns included mild breast discomfort and hand fatigue dur-
ing expression, mild anxiety if no milk could be expressed,
and inability to use antenatal milk in the hospital setting due
to forgetting at home, inadequate hospital storage options,
and unsupportive medical staff. In terms of fit with life,
AME was typically practiced at home before or after the
workday, with few privacy or time concerns.
Conclusions: With few caveats, our data suggest that AME
is a feasible and acceptable breastfeeding support interven-
tion among high socioeconomic status, white, first-time
mothers. Further study addressing feasibility and impact of
AME on breastfeeding outcomes is indicated among more
diverse groups of women.
Physician (Lack of) Training in
Breastfeeding and Human Lactation
Eden, A. R., PhD, MPH
American Board of Family Medicine, Lexington, KY, USA
Background: Physician advice and support have been
shown to have a significant impact on breastfeeding initiation
and duration. However, the strongest predictor of physicians’
clinical breastfeeding advocacy is their personal or spousal
breastfeeding behavior. Further, studies on physician knowl-
edge and attitudes about breastfeeding have shown that their
training is not adequate and the care they provide is often not
evidence-based. While the specialty medical associations for
pediatrics, obstetrics and gynecology, and family medicine in
the United States each have policy statements supporting
breastfeeding, there is no standard curriculum or core compe-
tencies required in their residency training programs. Indeed,
the amount and content of breastfeeding training varies by
specialty and residency program within each specialty. Some
physicians become International Board-Certified Lactation
Consultants (IBCLCs) as a way to acquire training, but this is
not common in the United States.
608 Journal of Human Lactation 34(3)
Purposes: The purpose of this discussion was to (a) under-
stand participant experiences as physicians or other health
care providers who work with physicians in caring for nurs-
ing parents and babies, (b) explore the role of physicians in
breastfeeding care and support relative to other breastfeeding
support workers, and (c) describe approaches to ensuring
appropriate and adequate training in breastfeeding and
human lactation for physicians.
Narrative: The role of physicians in breastfeeding sup-
port and attention to medical issues that occur in nursing
dyads is unclear. While physicians not adequately trained
can refer to IBCLCs, these allied health professionals can-
not diagnose, prescribe medication, or treat certain condi-
tions unless they are trained as nurse practitioners,
physician assistants, or physicians themselves. Also in
question is the amount and level of training physicians
should receive and from whom. Lactation management
rotations with IBCLCs, didactic training, process-oriented
training, formal curricula, and performance improvement
projects for residents and practicing physicians are ways in
such training could be delivered to physicians. A physician
certification in breastfeeding offered by the International
Board of Lactation Consultant Examiners or the Academy
of Breastfeeding Medicine may be a way to indicate train-
ing in breastfeeding and human lactation to patients seek-
ing this expertise.
Conclusions: Physicians in various specialties have an
important role in supporting breastfeeding dyads, particu-
larly when clinical issues require medical attention. Thus,
physicians need adequate training so that they can treat or
appropriately refer patients.
From the NICU to Home: Parents’
Erices, P.
Special Kids, Special Care, Inc., Jefferson County Public
Health Department, Denver, CO, USA
Funding: Newborn Hope Grant
Background: Despite continuing efforts to reduce prema-
turely worldwide, a significant number of infants are born
less than 37 weeks of gestation, less than 2,500 g, or in a
fragile medical condition. Premature infants usually spend
weeks or months in a neonatal intensive care unit where
their parents receive services and support; however, after
they transition from the neonatal intensive care unit to the
home, families usually face challenges to connect with ser-
vices that affect the physical and mental health with long-
lasting impacts.
Purpose: Health care providers would benefit from expand-
ing their understanding of the impact of the neonatal inten-
sive care unit (NICU) stay based on families’ experiences in
order to implement effective and sensitive follow-up pro-
grams. Family voices and experiences provide guidance and
connection to the lived experience of families and their
needs in the neonatal intensive care unit and as they prepare
to go home, in the first days after transition, and in the first
years of life.
Narrative: Twenty-seven families from different back-
grounds and experiences who had had an infant in the neo-
natal intensive care unit in the last 3 years were interviewed
in an informal home setting. Parents received at $25 gift
card for their participation. Semi-structured interviews
lasted 1.5 hours and included open-ended questions, Likert
scales, and checklists. Interviews were analyzed, and three
main themes were identified. The NICU experience was
described as a stressful environment where parents tried to
establish their parental role through seeking information or
becoming actively involved in the care of their infants. The
transition home was described as unsettling, and they
reported feeling unprepared to care for their infant. After
going home, parents described feeling isolated; family and
friends were usually not able to help, work situations
changed leading to financial concerns and changes in social
network, and infants’ needs required them to stay home for
long periods of time. Interesting findings were consistent
conversations about identity development as a “NICU
mom”; mothers described it as being anxious, vigilant, and
always comparing their child with other children the same
age as well as strong, resourceful, and determined. The role
of the lactation consultant was described as a consistent
provider in the NICU; the lactation consultant can recog-
nize families’ needs for lactation and mental health support
during the NICU stay and after discharge. Parents described
strong connections with their lactation consultant, even
when they are not able to breastfeed or chestfeed; however,
as families transition, home their access to adequate lacta-
tion support was limited.
Conclusions: Families need support and guidance to pre-
pare to leave the NICU, during the transition, and long term.
NICU follow-up programs that include lactation services
could be a strategy to guide families through the adjustments
of bringing a premature infant home. Families connect with
their lactation consultant in the NICU and wish to sustain
lactation in the long term.
Connecting With Patients/Clients Through
Esposito, M. L., Sprague, J., & Zeledón, J.
Mothership, Grand Rapids, MI, USA
BFIC Abstracts 609
Background: Mothership is a nonprofit organization focused
on creating positive experiences for parents with health care.
Mothership aggregates peer-reviewed information, evidence-
based practices, and practical tools from the health care, psy-
chology, human behavior, and human-centered design fields
into workshops for a range of health service providers on top-
ics related to building connection and promoting empower-
ment. Mothership created this storytelling workshop for
lactation support providers. Research shows us that connec-
tion and empowerment in health settings can contribute to
better patient satisfaction and health outcomes. Storytelling
provides a tool for connecting with patients. Listening to sto-
ries has the power to resonate with our emotions and cue oxy-
tocin release, stimulating empathy, compassion, generosity,
and trust. Storytelling can help health service providers empa-
thize with their patients, successfully communicate complex
information, help their patients make sense of their experi-
ences, build trust, and encourage and empower their patients
to achieve their health goals.
Purpose: This workshop focused on understanding the
value of communicating and connecting with patients/cli-
ents through storytelling and provided practical tools for
doing so within the context of lactation support. There were
five workshop session objectives: (a) describe the science
behind connecting through stories, (b) list research that
supports that value of storytelling in health care, (c) describe
storytelling techniques relevant to lactation support, (d)
create stories for different patient/client and lactation sup-
port scenarios, and (e) list ways to encourage patient/client
Narrative: Throughout the workshop, we read stories
about family experiences with breastfeeding and reflected
on our own storytelling practices as lactation support pro-
viders, teachers, students, and advocates. We discussed the
following topics in detail: How can societal metanarratives
conflict with personal narratives related to parenthood and
infant feeding, and how does that impact breastfeeding
experiences? How do you encourage patients/clients to tell
their stories, and how do you give them the space to do so?
How can our choice of metaphors to describe parenthood
and the breastfeeding experience be empowering, disem-
powering, or both, depending on context? How do we
appropriately use redemption stories in the context of lacta-
tion support to provide encouragement? And how can we
use storytelling to make complex health information under-
staff memorable?
Conclusion: Integrating storytelling techniques into lacta-
tion support practice has the potential to help build stronger
connections grounded in empathy and trust between lactation
support providers and their patients/clients. These stronger
connections may also help contribute to improved patient/cli-
ent satisfaction and health outcomes. This workshop provided
an opportunity for attendees to build knowledge related to
storytelling, reflect on the use of storytelling in their own
practices, and learn from their peers through discussion.
Breastfeeding and Media: Exploring 200
Years of Conflicting Discourses
Foss, K. A.
Associate Professor, Media Studies, School of Journalism,
Middle Tennessee State University, Murfreesboro, TN, USA
Background: It has consistently been established that
media messages normalize and shape public perceptions of
breastfeeding. In fact, the Surgeon General’s Call to Promote
Breastfeeding, the American Academy of Pediatrics, and
other public health entities address improved utilization of
mass media as key to increasing breastfeeding initiation and
duration. Yet media have offered, at best, mixed messages
about breastfeeding, demonstrating the gap between legal
protection and public perception.
Aim: This research draws from Breastfeeding and Media:
Exploring Conflicting Discourses That Threaten Public
Health (Palgrave Macmillan, 2017), my comprehensive
analysis of media’s constructions and influence on breast-
feeding. In this book, I examine media texts dating back to
wet nurse advertisements of the 18th century, exploring how
breastfeeding rates and perceptions have fluctuated with
changing cultural ideologies and the emergence and domina-
tion of commercial formula. Through an analysis of more
than 200 years of media texts, I explore how breastfeeding
rates and perceptions have fluctuated with changing cultural
ideologies and the emergence and domination of commercial
Narrative: A textual analysis was conducted on ads for wet
nurses (1700s-contemporary times); infant feeding articles
and advertisements in Ladies’ Home Journal and Practical
Housekeeper, 1885-1907; breastfeeding articles in the New
England Journal of Medicine and JAMA; early 20th-century
mothering manuals; infant feeding articles and advertise-
ments in Parents magazine, 1930-2007; and popular con-
temporary “new parent” books, children’s books, reality and
fictional television, social media, and YouTube videos. This
methodology and sample enabled a comprehensive look at
media’s constructions of breastfeeding. This comprehensive
cross-media analysis identifies conflicting discourses in
how media messages talk about breastfeeding. Such polar-
izing frames include the scientific and cultural conceptual-
izations, feminist questions of breastfeeding, and discourses
of the “Mommy Wars”—a formula marketing strategy that
undermines women’s confidence and reinforces individual
responsibility. Overall, I show how media shapes and rein-
forces customs and cultural attitudes toward human feeding
610 Journal of Human Lactation 34(3)
practices, breastfeeding, and the female body while perpetu-
ating a heteronormative hegemonic structure that narrowly
defines the “breastfeeding mother.”
Conclusion: This research demonstrates ways in which
media potentially undermine breastfeeding success, empha-
sizing individual intention and behavior, instead of high-
lighting the numerous cultural and institutional obstacles
that discourage parents from meeting their breastfeeding
goals. This recognition of media’s potential ability to posi-
tively influence social contexts is a key step to creating a
culture that celebrates and encourages all breastfeeding
The ABCs of Creating, Building, and
Sustaining Community Partnerships for
Breastfeeding Promotion
Freeman, A.1, Gise-Johnson, A.1, Bodnar-Deren, S.2, Hamlin,
T. K.3, Lewis, R.3, & Karriem, B.3
1Virginia Union University School of Theology; 2Virginia
Commonwealth University School of Sociology; 3Healthy
Heart Plus II, Richmond, VA, USA
Background: The Mommies Bellies Babies & Daddies
Outreach Program format and the ABCs of Breastfeeding
curriculum was developed in 2011 with urban youth preg-
nancies and women of color in mind. The difficulties and
decisions about breastfeeding faced by women who are
young, poor, and/or women of color are largely invisible to
policy makers. Inequities in breastfeeding promotion (BP)
affect breastfeeding rates. BP planners and programming are
rarely connected to organizations that women trust or found
in neighborhoods. The purpose of the Mommies Bellies
Babies & Daddies community-based participatory action
projects are to examine urban community breastfeeding sup-
ports with respect to recruiting and retaining women of color
and increasing rates of breastfeeding initiation, duration, and
Narrative: In 2015, a local grassroots, nonprofit Healthy
Hearts Plus II (HHP II) breastfeeding promotion team
joined forces with local and national supporters as part of
the National Association of County and City Health
Organizations (NACCHO), Breastfeeding Project in
Richmond, Virginia. HHP II proposed the Mommies Bellies
Babies & Daddies (MBBD) Outreach Program format and
the ABCs of Breastfeeding curriculum and mobilized the
community to address unmet needs that affect breastfeed-
ing decisions and create barriers. MBBD braids supports
from food pantries, Federally Qualified Medical Centers,
Saint Paul’s Baptist church community garden, domestic
violence advocates, and university researchers. MBBD vol-
unteers cross-train as community researchers and outreach.
The outreach goal is to create relationships with the family
ecosystem: mothers, grandmothers, friends, neighbors.
Then “hard to find women” simply show up on word of
mouth. To build on relationships, MBBD integrates incen-
tives like mommy support bags with diapers, breast pads,
and other breastfeeding support items and supports like
monthly “sister circles,” facilitated by women of color. In
support groups, many women, who have no other access to
veteran breastfeeders, are able to discuss everything, nutri-
tion, lactation, and all things parenting, including struggles
with stress. The most important work is sustaining the rela-
tionships. HHP II focuses on continuous improvement of
the person-centered programming, facilities, and curricu-
lum that are foundations of culturally relevant breastfeed-
ing promotion. Funding comes from philanthropy, social
enterprise, and research partnerships.
Conclusion: Following the basics from the NACCHO
Mobilizing for Action through Planning and Partnerships,
MBBD helped create, build, and sustain strategic partner-
ships and taught the community to prioritize relationships
with women who are making decisions about breastfeeding.
MBBD also raises awareness of the value of creating, build-
ing, and sustaining:
1. targeted socio-emotional support for new breast feed-
ers during pregnancy
2. positive cues (e.g., breastfeeding suites or other infra-
structure) in the community landscape
3. baby-friendly learning opportunities and events for
4. engaging families with infants beyond 6 months
5. culturally relevant role models.
Since 2014, the Mommies Bellies Babies & Daddies has suc-
cessfully raised breastfeeding rates among women of color,
with a large percentage of participants still deciding to breast-
feed beyond 4 months. Despite economic hardship, power
imbalances, and historical and institutional barriers, the tradi-
tion of breastfeeding is being fostered in underserved com-
munities by passionate women and grassroots organizations.
Are State Laws and Regulations
Supportive of Breastfeeding?
Gonzalez-Nahm S., Grossman, E., & Benjamin Neelon, S. E.
Department of Health, Behavior and Society, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD, USA
Funding: This study was supported in part by a grant from the
Robert Wood Johnson Foundation (New Connections #127050, and
Healthy Eating Research #73391) and the Lerner Center for Public
Health Promotion at Johns Hopkins Bloomberg School of Public
BFIC Abstracts 611
Background: Although breastfeeding initiation rates in the
United States have slowly increased, rates of breastfeeding
continuation continue to be low, especially among women of
color. Although multiple factors affect a woman’s ability and
decision to breastfeed, policies determine the parameters within
which a woman is able to make feeding-related decisions.
Aim: We reviewed existing state policies related to breast-
feeding using an equity framework and assessed correlations
with state breastfeeding rates.
Narrative: We identified state policies related to breast-
feeding for all 50 states and the District of Columbia and
grouped them into categories, including workplace laws,
hospital laws, and child care regulations. We reviewed
each set of policies and then assessed correlations between
the existence of policies and state breastfeeding rates. We
then qualitatively assessed the text of each policy using
keyword searches to determine if the policy was created
with intentional equity. All states had at least one law
related to breastfeeding. We found no correlations between
the existence of state breastfeeding laws and regulations
and breastfeeding rates; however, temporality is an issue
as several laws were enacted after the breastfeeding data
were collected. We found no intentional equity in state
breastfeeding laws.
Conclusions: The results of this research may highlight the
lack of breastfeeding support at the state policy level and the
need for intentionally equitable policies to help support all
women in their decision to breastfeed and reduce disparities
in breastfeeding.
Breastfeeding Self-Efficacy Between
Adolescent and Adult Mothers:
Analyses From the Perspective of
Women’s Right
Guimaraes, C. M. S., Gomes-Sponholz, F.,
& Monteiro, J. C. S
Ribeirao Preto College of Nursing, University of São Paulo
at, Sao Paulo, Brazil
Background: Breastfeeding is considered the gold standard
of infant feeding by World Health Organization, and its ben-
efits are already widely described in the scientific literature.
However, exclusive breastfeeding rates around the world are
lower than recommended, including the Brazilian rates. The
maternal confidence for breastfeed, called breastfeeding
self-efficacy, is a variable that is related to the initiation and
duration of breastfeeding. It includes the desire of women to
breastfeed or not; however, their desire sometimes is not
respected by health professionals.
Aims: Our aims were to (a) identify breastfeeding self-effi-
cacy between adolescent and adult mothers in the immedi-
ate postpartum and (2) analyze the association between
socioeconomic and obstetric characteristics with breast-
feeding self-efficacy levels from the perspective of wom-
en’s rights.
Narrative: This is an observational, cross-sectional, and
descriptive study, developed at a maternity hospital in
Ribeirao Preto, São Paulo State, Brazil. Data were collected
between January and July 2014 using a questionnaire on
sociodemographic and obstetric information and the
Brazilian version of the Breastfeeding Self-Efficacy Scale
(BSES). The sample consisted of 400 mothers, with 306
adults and 94 adolescents. Most adolescent (n = 54, 26%)
and adult mothers (n = 54, 58%) presented high levels of
breastfeeding self-efficacy, and there was no statistical sig-
nificant difference between scores of adolescent and adult
mothers (p = .348). Among adolescent mothers, the high lev-
els of breastfeeding self-efficacy were associated with these
variables: support of their mothers or mothers-in-law during
the postpartum period (p = .0083), breastfeeding at the first
hour of life (p = .0244), and exclusive breastfeeding at the
maternity hospital (p = .0148). Among adult mothers, there
were significant association between breastfeeding self-effi-
cacy and the variables: black or brown skin color (p = .0304)
and high educational level (p = .0280). Our results show that
there were different variables that influenced the breastfeed-
ing self-efficacy in the immediate postpartum between
Brazilian adolescent and adult mothers. Furthermore, it is
important to consider that the women’s choice to breastfeed
is a woman’s right. In this sense, health professionals should
use verbal persuasion that is an information source for breast-
feeding self-efficacy in order to offer qualified assistance
and adequate information. Thus, women could have an
improvement in their self-efficacy and could make the best
decision about breastfeeding based on the right information
and according to their context of life.
Conclusion: The health care professional support is an
important source of information that could influence breast-
feeding self-efficacy and consequently the women’s choice
to breastfeed. Therefore, the breastfeeding support to moth-
ers should consider individual characteristics of each
woman. It can contribute to improve self-efficacy and
breastfeeding rates.
Using Human Milk for Artwork and
Food: Is It Ethically Acceptable?
Hidayana, I.
Teachers College, Columbia University, New York City, NY,
612 Journal of Human Lactation 34(3)
Background: Breastfeeding confers benefits on both child
and mother for the short term and long term and is a key to
newborn and child survival intervention. Thus, the World
Health Organization recommends the initiation of breast-
feeding within an hour after birth, exclusive breastfeeding
for the first 6 months of life, and continued breastfeeding
throughout the second year of life or beyond, with safe and
adequate complementary feeding. Interestingly, we found
several alternate practices of using human milk in the past
few years. They include using human milk for ice cream,
cheese, soap, and the most recent one, jewelry. “Baby Gaga”
ice cream first appeared for public sale in 2011 in London,
then it appeared again in 2015 as “Royal Baby Gaga” ice
cream with profits donated to a breastfeeding charity. In
2010, a New York–based chef, Daniel Angerer, served
human cheese in his restaurant. The next year, Miriam
Simun, a New York–based interdisciplinary artist, made
human cheese as an art project. In 2017, Natasha Tontey, an
Indonesian artist, has also used human milk as one of her
artworks. Moreover, some women turn human milk into jew-
elry and soap. Are these practices ethically acceptable?
Purpose: Is the use of human milk for artwork or food ethi-
cally acceptable? I propose aspects to consider when using
human milk for other purposes than feeding infants and
young children.
Narrative: Human milk is also beneficial for adults with
various medical indications and is therapeutic, nutritional,
preventive, and palliative. Artists and those who use human
milk for ice cream, cheese, or other foods should be aware
that despite its numerous benefits, human milk could pose
some risks, including exposure to infectious diseases, includ-
ing HIV, to chemical contaminants (e.g., to a limited number
of prescription drugs that might be present in the milk) if the
donor has not been adequately screened. Moreover, it is
important to know that human milk must be handled and
stored properly to prevent contamination and exposure from
disease. Practices of using human milk for artwork or food
can also be considered insensitive to the fact that many moth-
ers lack breastfeeding support. In a setting where many
mothers do not receive appropriate breastfeeding informa-
tion and education, instead of making an artwork from
human milk, there is a critical need to support mothers to be
able to breastfeed optimally, including through a contempo-
rary approach. A contemporary approach (artwork) in sup-
porting mothers to breastfeed can help them and increase
society’s awareness of the importance of breastfeeding.
Conclusion: Therefore, using human milk for artwork,
food, jewelry, and other purposes instead of its natural pur-
pose of feeding infants and young children must consider
numerous aspects. First, it is imperative to prioritize the pri-
mary function of human milk as the most appropriate food
for infants and young children; second, getting consent from
the human milk donors; and third, appropriately screening
the milk to prevent any possible health risks to those who
consume the products.
Mothers on the Market: Human Milk
Exchange and Blurring the Boundaries
Between Love and Work
Lee, R. K.
University of Alberta, Edmonton, Alberta, Canada
Background: The relationship between the economic mar-
ketplace and the private life of families has long been highly
fraught. Growing numbers of women participate in the paid
workforce, and increasingly two incomes are required to
maintain a standard of living that used to be sustained by a
single income. This has coincided with an erosion of the
social welfare state and a downshifting of responsibility for
care work onto the family. In this context, paying women for
their human milk emerges to address the difficulties faced in
attempting to combine breastfeeding with paid employment.
Purpose: Drawing on feminist political economy, I explored
how the exchange of human milk demonstrated the inade-
quacy of distinctions between productive and reproductive
labor that have long been critiqued in the feminist tradition.
Narrative: Consistent with the global outsourcing of
domestic labor, markets in human milk are transnational.
However, this raises ethical questions about the global
exploitation of women and the commodification of bodily
tissues and has led to regulatory initiatives to restrict and
even outright ban the sale of human milk.
Conclusion: The production and exchange of human milk
destabilizes the boundaries between love and work and between
the public and private realms. Addressing the dangers of com-
mercializing human milk exchange must go further than merely
attempting to keep the private realm free from the encroach-
ment of the marketplace to take up a more nuanced understand-
ing of how love and care are connected to global inequality.
Community-Based Intervention to
Enhance Exclusive Breastfeeding in
Hispanic Women
Linares, A. M., Rayens, M. K., & Dignan, M.
University of Kentucky College of Nursing, Lexington, KY,
Funding: The NIH National Center for Advancing Translational
Sciences (#UL1TR000117 and #UL1TR001998).
BFIC Abstracts 613
Background: Exclusive breastfeeding is the most effective
intervention for improving child survival and health. Hispanic
mothers typically initiate breastfeeding but also provide early
introduction of formula and other solids, including ethnic
foods. For some Hispanic women, mixed feeding is consid-
ered acceptable, desirable, and not harmful.
Aim: To determine the feasibility and evaluate the clinical
impact of a novel, tailored, culturally and linguistically
appropriate, community-based intervention designed to sup-
port Hispanic mother/infant dyads to exclusively breastfeed
(EBF) for a longer time.
Narrative: A two-group randomized, controlled trial design
was used to assess the efficacy of an intensive Peer Counselor
and Lactation Professional (IBCLC) intervention that included
prenatal educational modules, phone calls, and hospital and
postpartum home visits. Hispanic pregnant women (N = 39,
split between intervention n = 20 and standard care n = 19) were
recruited in a local outpatient clinic in central Kentucky and fol-
lowed until 6 months after the birth of their infant. The groups
did not differ in demographic or social characteristics. Most of
the participants were from Mexico, lived with their partner, did
not work out of home, did not have health insurance, and this
was not their first pregnancy. The majority of participants deliv-
ered a healthy term infant via vaginal birth. The main effect of
group on intention to breastfeed was significant (with interven-
tion > control in intention; p = .03), while the main effect of time
and group by time interactions were not. We conducted group
comparisons of breastfeeding self-efficacy at 1, 3, and 6 months
after birth, which showed that neither the main effects nor the
interaction effects were significant for this outcome. EBF was
higher in the intervention group at discharge from hospital stay
with 45% of mothers in the intervention group compared with
21% of control group participants; however, this difference was
not significant (p = .14), with infant gestation age as a covariate.
For each of the comparisons (at 1, 3, and 6 months), the percent
of mothers still EBF was higher in the intervention group than
control group (Figure 1), but the p values for these between-
group comparisons had p values of .052, .13, and .051 for 1, 3,
and 6 months, respectively.
Conclusion: This pilot study produced important information
in terms of identifying key components to refine and increase
the fidelity of the intervention and plan for future recruitment
and retention. The small sample size limited the statistical
power, which resulted in few significant group differences
(with some close to significance). Still, the results suggest that
the intervention supported both intentions to breastfeed during
pregnancy and EBF status following birth. This culturally and
linguistically adapted intervention with professional/peer
counselor support during pregnancy and postpartum has the
potential to have great impact on the duration and exclusivity
of breastfeeding in Hispanic mother/infant dyads. Further test-
ing of this intervention with a larger sample is warranted.
Erasure or Inclusion? Finding Space
for Chestfeeding in the Breastfeeding
MacDonald, T.
Author, Community Activist, Blogger, Ottawa, Canada
Background: Many lactation support organizations, hospi-
tals, and private practice lactation consultants are currently
in the midst of making decisions about using gender-inclu-
sive language. Transgender and nonbinary parents require
access to lactation support that is welcoming and addresses
their needs. Being a first-time parent involves learning a
whole new set of skills and making a major life adjustment.
In addition to these challenges, transgender and nonbinary
parents might also need to cope with aversive stressors such
as gender dysphoria or social stigma and exclusion. Health
care providers can help transgender and nonbinary parents
feel empowered by using inclusive language and supporting
their parenting goals and choices.
Aim: This presentation drew attention to the real impact of
exclusion on transgender and nonbinary parents, focusing on
how exclusion and inclusion feel and how they affect behav-
ior and learning. An intersectional analysis was used to
understand how gender inclusion may relate to and work
with a feminism that resists a historically patriarchal medical
Narrative: The author discussed a qualitative research
study based at the University of Ottawa and funded by the
Canadian Institutes of Health Research. The study exam-
ined the experiences of 22 transmasculine individuals with
pregnancy, birth, and infant feeding. Through NVivo anal-
ysis, researchers Trevor MacDonald, Michelle Walks,
Marylynne Biener, and Alanna Kibbe identified themes
that included gender dysphoria and intersectionality.
Participant experiences of gender dysphoria varied and
Figure 1. Group comparisons of exclusive breastfeeding status
at discharge, 1, 3, and 6 months (N = 39).
614 Journal of Human Lactation 34(3)
could be categorized as breast/chest-related, hormonal,
genital, social, or a combination of the aforementioned. In
all cases where it was experienced, gender dysphoria was
described as aversive and stressful. Some participants
remarked that they did not experience gender dysphoria
while nursing their babies, but for others, gender dysphoria
prevented them from chestfeeding. At times, gender dys-
phoria seemed to be triggered by the actions of care pro-
viders, such as manipulating the chest tissue without prior
warning or consent. Experiences of intersectional oppres-
sion described by study participants included struggles
based on age, immigration status, and being patients in a
patriarchal medical system, in addition to identifying as
transmasculine. Rather than gaining power in the birthing
and lactation worlds by identifying as transmasculine,
some study participants described being thrust into a medi-
cal system as patients who lost control over their health
care decisions, not dissimilar to cisgender birthing women.
Conclusion: Our study supported previous research that
found that transgender patients sometimes avoid medical
care due to the fear that they will have negative experiences
because of their transgender identity. Triggers of gender dys-
phoria as well as social exclusion may constitute powerful
aversive that affect a patient’s choice to seek medical care,
including lactation care. The history of obstetrics as a patri-
archal system affects transgender and nonbinary individuals
as well as cisgender women; therefore, all of these identities
should be acknowledged and included in the language used
by lactation experts.
“What Can I Do?” Practical, Positive
Steps Toward Gender Inclusion
MacDonald, T.
Author, Community Activist, Blogger, Ottawa, Canada
Background: Patients frequently make initial contact with
International Board-Certified Lactation Consultants
(IBCLCs) and other lactation helpers by viewing websites,
intake forms, and information handouts. They may feel dis-
empowered or even hesitate to seek help if the language in
such materials is exclusionary. Lactation consultants may be
unaware of key terms and concepts that relate to gender iden-
tity, or they may struggle with using inclusive language when
speaking with clients. Furthermore, a lactation consultant
may be called on to act as an advocate when dealing with
other health care providers working with their client.
Unfamiliar or unanticipated clinical problems faced by queer
clients may include difficulty latching to a postsurgical chest
(in the case of a transmasculine person who had chest mascu-
linization surgery), learning about safe binding or flattening
of the chest during the lactation period, and minimizing gen-
der dysphoria while feeding.
Aims: The purpose of this workshop was to provide a safe,
positive, and engaging learning environment for IBCLCs and
other lactation helpers to develop the skills necessary to culti-
vate a gender-inclusive practice. Learning was highly partici-
patory and included role-playing and group discussion.
Narrative: We began by defining key terms such as sex,
gender, intersex, gender identity, gender dysphoria, and
gender expression. During role-play, workshop participants
practiced using inclusive language with clients and teach-
ing other health care providers about respectful communi-
cation with queer clients, practicing acts of “allyship” (e.g.,
educating other providers or correcting their pronoun use
was sometimes more difficult). During group discussion of
examples from intake forms, we learned that there may be
a disconnection between what typical consent forms state
clients must be prepared for and IBCLCs’ actual expecta-
tions of their clients. For instance, several intake forms that
we analyzed required a client’s signature to show they con-
sent to physical examination, including manipulation of the
“breast” tissue. Workshop participants strongly agreed that
this is not always necessary and that if a client is uncom-
fortable with such procedures they should have the right to
opt out of them. It was pointed out that this type of lan-
guage on intake forms could result in queer clients’ avoid-
ance of care.
Conclusion: Defining key terms for the group and role-
playing in front of the group was sometimes awkward for
workshop participants, yet these exercises brought gender
inclusion out of the realm of the theoretical and into prac-
tice. Workshop participants’ confidence seemed to grow as
the session progressed. The participants’ experiences sug-
gest that using inclusive language and advocating for queer
clients are skills that must be nurtured to become habits.
Language on intake forms should be considered diligently
from the perspective of transgender and gender-noncon-
forming individuals to protect these clients’ access to lacta-
tion services.
Strategies for Implementing the Infant
Feeding Guidelines in Child Care
Settings: National Policy Implications
From the Australian LEAPS Project
McGuire, J. M.
Queensland University of Technology, Faculty of Health and
Exercise Science, Brisbane, Australia
Background: Early childhood and care (ECEC) settings are
becoming an increasingly important context for health due to
the number of children attending child care and the length of
time spent in these environments. According to UNICEF, in
BFIC Abstracts 615
developed countries, approximately 25% of infants and chil-
dren up to the age of 3 and 80% of children from 3 to 6 par-
ticipate in a form of child care. Despite guidance from the
WHO and Australian Infant Feeding Guidelines to the han-
dling, preparation, and feeding of infant foods including
expressed mother’s milk, infant formula, and complemen-
tary foods, convincing evidence implies that public and ser-
vice policies and ECEC educator knowledge around infant
feeding is often deficient.
Aim: The Learning, Eating, Active Play and Sleep Project
(LEAPS) was an Australian Commonwealth Government
initiative for applying the National Healthy Eating and
Physical Activity Guidelines in ECEC, encompassing a key
focus on infant feeding and physical activity. LEAPS
acknowledged the essential role of early educators in pro-
moting healthy choices with the aim to build capacity around
guidelines with professional development funded by the
Queensland Government from 2013 to 2016 reaching ECEC
educators (N = 3,255). This nested qualitative research
directly contributed to the understanding of the public/ser-
vice policy and the educator role in infant feeding in formal
care settings.
Narrative: Qualitative data were collected through semi-
structured interviews with child care and home-based care
service directors, educator professional conversations, ser-
vice audits, and a national ECEC policy audit and nutrition
policy analysis with 19 services in areas stratified by
regional, metro, high/low socioeconomic ratings. Thematic
analysis following the Framework method was undertaken
using both inductive analysis and deductive approaches
underpinned by social cognitive theory. Content analysis
was also applied to public policies within the ECEC
Australian National Quality Framework. Analyses empha-
sized important enablers of infant feeding in Early Education
and Care as the provision of supportive environments. The
focus of the discussion on public and service policies out-
lined five emergent themes: values, documentation, curricu-
lum and pedagogy, supportive environments—with an
emphasis on health and safety, and communication with par-
ents. Few examples for infant feeding existed in legislation,
which increased ambiguity and infant risk.
Conclusion: Access to early quality education with well-
trained educators and visibility of infant feeding in both public
and service policies is essential to implementing dietary guide-
lines on a national basis to inform best practice for infants and
children. This research practically informs the important train-
ing and educational practice with the use of guideline nutrition
resources and developing collective efficacy of child care edu-
cators toward best practice infant feeding in ECEC. It offers
key strategies for positive child-centered health education
with policy implications for global application.
Patching the Gaps: How Online
Support Shapes Breastfeeding Practices
in Poland
Mecinska L. M. W.
Department of Sociology, Lancaster University, Bowland
North, Lancaster University, Lancaster LA1 4YN, United
Background: Initiation rates for breastfeeding in Poland are
high, but they dwindle swiftly from the third month mark.
Despite availability of a long maternity leave and a universal
maternity benefit, breastfeeding in Poland is marked by a
context of failing legal protections and lack of institutional
support beyond the language of “promotion.” While WHO
Code has been adopted, it is not enforced, and routine hospi-
tal practices mean that as many as a third of infants are sup-
plement-fed without parental consent within the first three
days of life.
Purpose: Drawing on six years of sustained participation
and observation in Polish breastfeeding support spaces
online, my research aim was to determine how peer-to-peer
breastfeeding support in these spaces shapes Polish parents’
experiences of breastfeeding.
Narrative: Health care professionals routinely provide par-
ents with inaccurate, dated, and even potentially harmful
advice on infant feeding and weaning practices. Just like the
families of many new mothers, professionals also draw on
“folk” beliefs and customs. This results in deficits of trust,
care, knowledge, and community. Breastfeeding women
increasingly turn to online environments—forums, Facebook
groups, blogs—to seek out support they are lacking in their
immediate contexts. This is helped by the relatively high
national access to Internet (90%). Parents’ experiences are
shaped by the digital mundane—high frequency, routine, and
ritualized participation in online environments—which
allows them to overcome spatial and temporal barriers to
access to lactation support. Online groups become communi-
ties of complaint but also of support—allowing breastfeed-
ing women to withstand pressures of their environment.
Groups provide interpersonal support and affirmation of
their choices as well as information on breastfeeding and
instruction on how to carry on with a breastfeeding relation-
ship. These forms are not easily separable: Information may
also serve to allay worries, and instruction can be a form of
support. Groups also employ a wide range of digital tools—
gifs, memes, stickers, emojis, links, documents—to create
easily accessible repositories of knowledge and establish a
supportive presence available around the clock. Participation
in these groups encultures women to stand their ground in
encounters with health care professionals. It also results in
positive definitions of breastfeeding—milk pride; higher
616 Journal of Human Lactation 34(3)
likelihood to initiate, continue, and carry to term breastfeed-
ing among members; new practices such as tandem feeding
and milk sharing; and demands for acceptance of public
breastfeeding. An interesting aspect of Polish groups is the
way they give rise to “emergent experts”—from in-group
“local experts,” through bloggers and credentialed experts,
to rising influencers—whose actions contribute to creation
of high-quality knowledge on breastfeeding. Their presence
is crucial to the group interactions and the growing acumen
of online environments that begins to transcend the digital
Conclusion: The work parents carry out within these spaces
is a form of “patching the gaps” in governmental and social
provisions. Groups also create a sense of “togetherness,”
which may translate into action and activism. As such, online
groups represent an important intervention at the grass-roots
level of the Polish breastfeeding movement. What remains to
be seen is how the activities of these groups will affect sys-
temic change.
Unpacking Emergency Response From
2017: Infant Feeding and Maternal
Health in Canada
Melaku, H.
Birth companion, Hirut Ltd., Montreal, Canada
Background: An unprecedented number of asylum seekers,
mainly Haitians who moved to the United States in the after-
math of the 2010 hurricane in Haiti, crossed the U.S./Canada
border in the summer of 2017 into Quebec. A third of the
~12,000 people who arrived were children. Among the asy-
lum seekers, there were many late-term pregnant women; we
saw 25 to 40 on any given day.
Purpose: We were a team of volunteers trained in emer-
gency infant feeding (IBCLCs, birth workers, activists),
under the umbrella of SafelyFed Canada-Montreal (SFC-
MTL) who sought information regarding existing emer-
gency protocols to address the needs of infants and pregnant
and lactating individuals (PLI) at the temporary shelters. We
conducted an emergency assessment and discovered that
there were no protocols in place to address infant feeding
and the needs of PLI. The following represents our major
findings and analysis of the situation in Montreal between
August 2017 and November 2017. As the team leader of the
volunteers, I found the response by government health offi-
cials and the Regional Program for the Settlement and
Integration of Asylum Seekers (PRAIDA) to be negligent.
Because of various barriers, asylum seekers did not have
their needs met, nor were they able to make informed medi-
cal decisions.
Narrative: Inside the temporary residence, we observed
unsafe handling, preparation, and storage of human milk
substitutes due to a lack of appropriate resources, support,
and education. Families used the sinks in bathrooms to wash
infant feeding devices such as bottles, cups, and teats. Our
black birth workers (doulas) and the community-based
nurses pointed out various systemic barriers to receiving pre-
natal care. For example, pregnant women past 32 weeks of
pregnancy were denied access to prenatal care by ob-gyn;
others expressed feeling “obligated” to consent to having an
x-ray when their fetus was under 12 weeks; and families in
general spoke of feeling overwhelmed and afraid. When it
was time to give birth, mothers reported feeling disempow-
ered, humiliated, disrespected, violated, and traumatized—
responses to what has been characterized as “obstetrical
violence.” Furthermore, some hospital practices contradicted
the Quebec government’s public health recommendations
regarding breastfeeding. To meet the needs of and advocate
for the rights of infants and pregnant and lactating individu-
als during crisis situations, I am proposing the development
of place-based Reproductive Justice Emergency Response
Teams (RJERT) prior to emergencies and crises. The teams
should include reproductive justice activists, birth workers,
lactation consultants, emergency response specialists, and
public health managers. Given that both manmade and natu-
ral disasters have been increasing in frequency and intensity
and that they disproportionately impact marginalized groups
such as women and racialized and low-income communities,
I recommend creating a Reproductive Justice Toolbox, with
a mandatory anti-oppression and anti-racism training for all
participants, to address obstetrical violence, gendered vio-
lence, intersectional oppression, and institutional racism, all
using accessible communication strategies.
Conclusion: The negligence demonstrated by the Canadian
and Quebec governments toward infants and pregnant asylum
seekers can be situated in a longer history of systemic racism
toward Indigenous people and racialized communities.
Implicit Bias and Clinical Breastfeeding
Miller, M. R.
Union Institute and University, Cincinnati, OH, USA
Background: As African American women are dispropor-
tionately affected by systemic health care disparities and con-
sistently have low breastfeeding rates, the ongoing examination
of factors contributing to breastfeeding outcomes in the
African American community is a public health imperative.
Implicit bias among breastfeeding providers may be one such
factor. While existing studies describe the presence of implicit
bias among health care providers, there is no current research
on implicit bias among clinical breastfeeding providers.
BFIC Abstracts 617
Purpose: The purpose of this study was to describe
implicit bias among International Board-Certified Lactation
Consultants (IBCLCs) and examine how clinician bias may
be an additional contributing factor to the existing barriers
to breastfeeding among African American women.
Narrative: Participation in an anonymous email survey
was requested of 175 IBCLCs from the Northeastern
United States. Twenty-eight IBCLCs completed the sur-
vey. Survey questions were included to measure explicit
bias among participants, and the Implied Association Test
(IAT) was used as a measure of participant implicit bias.
Despite the stated neutrality of the vast majority of partici-
pants (89%), results revealed a mostly moderate level of
automatic preference (64%) for European children com-
pared to African American children. More than three-quar-
ters of participants providing information about race/
ethnicity were white, and most worked in hospital and pri-
vate practice settings. Majority participants reported nega-
tive reactions to their IAT results. Responses to open-ended
questions about why breastfeeding rates among African
American women are consistently low and how to address
this focused primarily on education, culture, and the need
for increased support.
Conclusion: Implicit bias exists among breastfeeding pro-
viders as it does for other health care providers. As the
IBCLC cohort is overwhelmingly racially and ethnically
homogenous, further studies are needed to examine how the
presence of implicit bias among clinical breastfeeding pro-
viders may affect breastfeeding outcomes for African
American women.
Cultural Strategies for Increasing
Human Milk Production by Nursing
Mothers in Ghana
Obeng, C. S.
Indiana University School of Public Health, Department of
Applied Health Science, Bloomington, IN, USA
Background: Globally, breastfeeding is known to be an
effective measure in promoting optimal development of a
child. However, mothers’ inability to produce milk for their
infants has consistently been correlated with mothers’ inabil-
ity to do exclusive breastfeeding for their infants.
Purpose: I examined Ghanaian nursing mothers’ strategies
for increasing human milk production for their babies.
Specifically, I sought to understand how intergenerational
strategies about human milk production were passed on to
nursing mothers. Respondents’ beliefs about whether these
strategies worked for them also were examined.
Narrative: An open-ended questionnaire that covered
respondents’ strategies about human milk production, who
taught them the strategies, and whether the strategies were
working for them were administered to 84 mothers in Cape
Coast, Ghana, in 2015. Snowball sampling procedure was
used to recruit the studied respondents. A public health nurse
who worked at Cape Coast with mothers was recruited as a
research assist to administer the questionnaire. She was
trained on research survey administration. The criterion for
inclusion in this study was being a nursing mother aged 18 or
older. The questionnaire completion was done in the homes
of the respondents. Thematic analysis was used as the study’s
analytical strategy. The mothers who completed the ques-
tionnaire were between the ages of 18 and 40 with a mean
age of 28.12. Majority of the mothers had secondary school
or less education (n = 75; 89%.) Only 9 mothers had univer-
sity education. Seventy-nine of the mothers were married, 4
were unmarried, and 1 was divorced. Eleven of them were
first-time mothers, and the rest had two or more children.
Forty-six (55%) of the respondents indicated that they ate
coco-yam leaves, palm nut, or groundnut soup in addition to
a variety of vegetables (e.g., carrots) and fruits such as green
pawpaw and Aiden fruit. Sixteen (19%) of the respondents
indicated that they ate corn dough porridge regularly alone or
sometimes with peanuts. Eleven (13%) of the respondents
noted that they ate roasted corn and peanuts as snacks with
the view to increasing their human milk. Eight (9.5%)
respondents smeared shea butter on their breasts, and three
(3.5%) had a cold bath and massaged their breasts with the
cold water after birth to increase their human milk. The most
emphasized finding was respondents eating palm nut soup
with vegetables or fruits. Majority (n = 69; 82%) of the
respondents learned their strategies from their mothers and/
or grandmothers. Also, majority of the respondents (n = 82;
97.5%) confirmed that the strategies they employed helped
them to increase their milk production.
Conclusion: The studied nursing mothers used a variety of
strategies to help increase human milk production for their
infants. Future studies will involve a laboratory investiga-
tion into the foods (used by the research participants) by
examining their connection with increasing human milk
Influence of Grandmothers’
Beliefs, Knowledge, and Attitude
on Breastfeeding Practices in
Southwestern Nigeria
Ogunba, B. O., & Bello, O. A.
Department of Family, Nutrition and Consumer Sciences,
Faculty of Agriculture, Obafemi Awolowo University, Ile
Ife, Nigeria
618 Journal of Human Lactation 34(3)
Background: The older generation, particularly the infant’s
grandmothers, play a central role in various aspects of preg-
nancy decision making and child rearing within the family unit.
In the first week of birth, this is generally an available support
for the breastfeeding mother. Grandmothers see themselves as
key providers of and decision makers in perinatal care prac-
tices. Grandmothers, however, transfer their knowledge and
practice to their daughters, which ultimately influence maternal
decisions. Support from grandmothers may have a great influ-
ence on the breastfeeding mothers’ decision on breastfeeding
initiation, duration, and continued breastfeeding.
Aim: To describe the knowledge, attitudes, and beliefs of
grandmothers about breastfeeding practices of mothers.
Narrative: The study was conducted in Ikorodu Local
Government Area of Lagos State, Nigeria. A total of 185
grandmothers were selected for this study using snowball
sampling. An interview schedule between February and March
2017 was used to collect information about the knowledge,
attitudes, and beliefs of grandmothers related to breastfeeding.
Four focus group discussions, which lasted for between 40 and
90 minutes, were analyzed. The discussion yielded cultural
reasons for the introduction of prelacteal feeding and discon-
tinuation of breastfeeding of infants. Data were analyzed using
SPSS version 20. Correlation analysis was carried out to
examine relationship between breastfeeding practices, knowl-
edge, and attitudes. We found that 667.6% of grandmothers
were still married, and the mean age was 56.7 ± 7.5. Only 20%
of grandmothers did not have formal education while 73% had
either primary or secondary education. Most (77.3%) of the
grandchildren were between the age of 1 to 12 months, 13 to
24 months (20.5%), and 25 to 36 months (2.2%). Majority
(87.6%) of the grandmothers claimed to have influenced their
daughters’ feeding practices. Only 24.3% of the grandchildren
were exclusively breastfed for 6 months. Children were given
formula (98.4%), glucose (94.6%), water (90.8%), and other
things such as herbal drinks. One-third (33.5%) of the children
also were breastfed after their first birthday. Reasons for termi-
nation of breastfeeding include teething/biting (30.3%), infant
not sucking well (10.8%), mothers did not like breastfeeding
(9.2%), and going back to work (13.5%). Half (56.2%) felt
that formula feeding was more convenient than breastfeeding;
however, they were confused about the benefit of human milk
compared with infant formula (79.5%). The level of knowl-
edge of grandmothers about breastfeeding was good (69.7%),
average (25.9%), and poor (4.4%). Less than half (45.9%) of
the grandmothers had positive attitude toward breastfeeding.
About 79.5% believed that human milk makes up a complete
diet for the infant; however, grandmothers believed that many
women are not able to make enough milk to feed their infant
(47.6%). A negative and significant association was present
between the grandmothers’ attitude (r = −0.428, p .01) and
positive association with knowledge (r = 0.206, p .01) about
the practice of breastfeeding.
Conclusion: It is concluded that grandmothers passed on
their knowledge, beliefs, and poor attitude toward breast-
feeding to their daughters. Grandmothers, however, encour-
aged prolonged breastfeeding. Intervention on improvement
of breastfeeding practices should include all stakeholders
that may influence breastfeeding practices, especially the
BREASTfeeding and the Workplace:
Integrating Frameworks Into Action
Olson, B. H.1, & Sigman-Grant, M,2
1University of Wisconsin-Madison, Nutritional Sciences
Department, Madison, WI, USA; 2MadJoy Consulting, Las
Vegas, NV, USA
Background: Despite the enormous effort of the public
health community (e.g., the U.S. Department of Health and
Human Service’s toolkit, “The Business Case for
Breastfeeding”) aimed at employers to adopt breastfeeding-
friendly policies and practices, the intended impact of more
working American women maintaining lactation has not
occurred. Only 40% of working women have access to both
break time and private space to accommodate their breast-
feeding needs. Currently, more than half of mothers return to
work after delivering their babies. Of these, four out of five
mothers start out breastfeeding, but less than half are still
breastfeeding at 6 months.
Narrative: Even in workplaces where accommodations are
available, lactating women may find it difficult to continue to
provide their infant with adequate amounts of their milk.
There is significant literature from management, human
resources and industrial relations, and organizational psy-
chology on theories and application as to how employees
deal with conflicts between work and family. One researcher
described organizational climate as “(employees’) percep-
tions of the events, practices and procedures and the kind of
behaviors that get rewarded, supported and expected in a set-
ting.” Other researchers have proposed factors that result in
an employee’s perceived organizational family support
(POFS): tangible support (consisting of information and
structure) and intangible support (consisting of emotional
practices), also called formal and informal organizational
support. Others have organized investigations to contrast
availability of supports to an employee’s perceived accessi-
bility of those supports. Similarly, the socioeconomic frame-
work depicts an individual, upon making a decision such as
breastfeeding, is surrounded by both immediate and distal
environments that influence how, and even if, their decision
can be executed. Workplace policies and practices are deter-
mined by the distal environment, internal demand, and
resource availability. The actual implementation of these
decisions, however, is frequently left to managers and
BFIC Abstracts 619
coworkers. Unlike other work-family support issues, the
term BREAST itself sets this issue apart. Although not fully
explored, there are implications that there is an interface at
which a working mother’s decision to sustain breastfeeding
meets the decision of those with whom she works. A recent
qualitative study describes how interpersonal communica-
tion between working women and their immediate managers
can create either challenges to or success of continued lacta-
tion. Likewise, we have found managers supportive of
breastfeeding employees but unwilling to initiate conversa-
tion on BREASTfeeding support. We found new mother
employees’ perceptions of the workplace climate of breast-
feeding support to be influenced by managers and co-work-
ers, as opposed to company policy. Mangers, by contrast, had
attitudes toward breastfeeding support influenced by com-
pany policies and their own previous experiences with
Conclusion: Researchers need to begin discussion on a new
framework to inform the development of breastfeeding sup-
port programs. This framework is critical to moving conver-
sations of BREASTfeeding in the workplace forward, over
and above difficulties of work-family balance. This effort
must expand beyond public health implications to include an
understanding of organizational considerations to providing
breastfeeding support through both policies and practices.
Expressions of Care: Milk Sharing,
Interembodiment, and the Senses
Palmquist, A. E. L.
Carolina Global Breastfeeding Institute, Department of
Maternal and Child Health, Gillings School of Global Public
Health, University of North Carolina at Chapel Hill, NC,
Funding: Wenner-Gren Foundation; Elon University
Background: This presentation addresses one of the key
conference themes: “the diversity of experiences and activi-
ties related to infant feeding and nurturing, specifically
around expressed human milk.” In this presentation, human
milk sharing refers to a commerce-free practice in which a
donor gives expressed human milk to another parent/care-
giver for the purpose of infant feeding. Scholarly and public
health discourses related to human milk sharing thus far have
focused on relative risks and benefits; the ways families
negotiate various risks of milk sharing; motivations for seek-
ing shared milk or giving milk; the critical biocultural dimen-
sions of lactation disparities; the interface of milk sharing,
milk banking, and profit-seeking activities; and media fram-
ing. What has been neglected in most studies of milk sharing
is the importance of intercoporeality in the experiences of
giving, feeding, and consuming shared milk.
Aim: To understand human milk sharing experiences using
narrative and ethnographic research.
Narrative: Data collection was initiated with an online sur-
vey of milk sharing experiences in the United States (N = 867).
A subset of respondents (n = 165) completed semi-structured
telephone interviews, and then key informants (n = 20) were
purposively selected for inclusion in a multisited ethnographic
study. Spouses/partners, family members, and friends were
recruited via snowball sampling. Narrative techniques were
employed to gather participants’ stories about their milk shar-
ing experiences. Interviews were recorded, transcribed verba-
tim, and coded for emergent themes using an iterative constant
comparison approach. Emergent themes were triangulated
with ethnographic field notes and previously analyzed survey
data to further ground the analyses. Key themes that are pre-
sented include: complex tapestries of care; milk sharing as an
interembodied experience; liminal, temporal, spatial, and rit-
ual aspects of milk sharing; infants’ agency and embodiment;
and the construction of narratives through sensory memories.
Conclusion: Refocusing milk sharing with the lens of inter-
embodiment attends to sensory aspects of this intimate care. It
provides a framework in which to examine the interwoven phe-
nomenological experiences of donors, parents, and babies. By
focusing on sensory dimensions of interembodiment, we are
able to gain insight into relationships that are variably formed,
transformed, and/or dissolved throughout various types of
social interaction. Human milk sharing often has been treated
as an alternative peer-to-peer economy in which there is a uni-
directional flow of milk and care. I argue that these orientations
are insufficient to understanding the embodied intersubjectivi-
ties and multilayered nuances of care, intimacy, and sociality
that are formed through giving and receiving human milk.
Reaching the Rural Indigenous Mothers
of Guatemala Through Care Groups
Parry, K. C.
Carolina Global Breastfeeding Institute, Gillings School of
Global Public Health, University of North Carolina at Chapel
Hill, NC, USA
Background: The “Reading & Responding to Your Baby”
pilot project is a Technical and Operational Performance
Support Program–funded project developed by Food for the
Hungry and the Carolina Global Breastfeeding Institute.
Founded in 1971, Food for the Hungry operates relief and
development programs in 18 countries with four core sectors
of intervention: health and nutrition, education, livelihoods,
and disaster risk reduction. The Carolina Global Breastfeeding
Institute served as consultants for the nutrition team to pro-
vide technical assistance on breastfeeding and complemen-
tary feeding content.
620 Journal of Human Lactation 34(3)
Purpose: To test the appropriateness and effectiveness of an
approach to strengthening the mother-child interaction to
improve child development as well as breastfeeding and
complementary feeding practices. The approach teaches
mothers in a small cluster of communities in Alta Verapaz,
Guatemala, to recognize and understand baby behavior and
communication cues and demonstrate new ways of respond-
ing to infant feeding and bonding needs.
Narrative: This project consisted of teaching approximately
200 mothers of children 0 to 23 months of age about infant
cue recognition, especially as it relates to hunger and satiety,
as well as providing mothers with skills needed for appropri-
ate responses to those cues using the Care Groups methodol-
ogy. Formative research that informed the educational
materials included a baseline survey, focus groups in the proj-
ect areas, and a barrier analysis of the behavior “speaking to
your child with affection during breastfeeding or complemen-
tary feeding.” Materials were translated to Spanish, and a
Q’uechi’ artist was hired to produce artwork for the materials.
The Care Group model is intended for use by NGOs in mul-
tiple countries where infrastructure allows adequate forma-
tive research to be done prior to adapting the content to the
local context. Care Groups use participatory methods of
teaching including the use of songs, drama, role-playing, and
troubleshooting of barriers for the adoption of new behaviors.
Mothers using two or more responsive breastfeeding or com-
plementary breastfeeding behaviors improved in the final
evaluation compared to baseline, as did recognition of full-
ness cues, engagement cues, and disengagement cues. Almost
90% of mothers who received the intervention said they
would recommend that a friend or neighbor hear the mes-
sages presented in the educational material.
Conclusion: This pilot was able to confirm feasibility of
teaching infant feeding and behavior cues to Q’uechi’ moth-
ers in Alta Verapaz, Guatemala, via Care Groups, and can be
adapted to other contexts as appropriate. The educational
module is currently being utilized in three regions, covering
over 180 indigenous communities where Spanish is a second
language. The lesson plan and flip chart are available freely
online in both English and Spanish via the FNS Network.
Breastfeeding Experiences of Mothers
Who Have Children With Special
Health Care Needs: A Case Study
Payne, S., & Obeng, C.
School of Public Health, Department of Applied Health
Science, Health Behavior, Indiana University Bloomington,
Background: Knowing that breastfeeding is crucial to the
healthy development of all infants, it is important to understand
its impact in children who are born with special health care
needs (CSHCN). In addition, internal and external support sys-
tems are a major indicator on whether a woman chooses to ini-
tiate breastfeeding; therefore, it is very important to understand
what role the hospital plays in encouraging the woman to
breastfeed even when a child is born with significant medical
Purpose: To describe the experiences and perceptions
among women related to breastfeeding a child born with spe-
cial health care needs.
Narrative: Interviews were conducted with three women
who gave birth in different decades (1987, 2006, and 2016)
and whose children had different special health care needs.
Participants were asked seven questions to assess their
experiences with breastfeeding, their perception of breast-
feeding and how these perceptions were developed, and the
overall beliefs and stigmas in the special needs community
related to breastfeeding. Constant comparative analysis was
employed during the extraction of relevant data. Recurring
participant responses were reduced into emerging categories
using the open coding method. The reoccurring themes
among the women indicated that there was no encourage-
ment from the hospital or hospital staff to breastfeed their
child with special health care needs. For the two women that
did choose to breastfeed, they possessed the confidence and
determination to breastfeed or at least try based on their
belief that human milk would be more helpful and healthy
for their child. While one woman did not breastfeed, she
shared the same belief regarding the benefits of breastfeed-
ing. The barriers identified with breastfeeding CSHCN were
the lack of education in mothers on the benefits to breast-
feeding, of education in professionals to educate mothers
how to adapt when needed to breastfeed a child with special
needs, the physical difficulties in breasting CSHCN, and
other priorities taking precedent over breastfeeding (i.e.,
child may have life-threatening concerns that need to be
addressed). The last aforementioned barrier leads to another
barrier of mothers being emotionally unable to mentally
commit to breastfeeding. Two participants mentioned how
having a child with a special need and not knowing until the
day the child was born is a very emotional time. It takes
some mothers and families time to understand and face this
reality. There was one stigma related to breastfeeding a child
with special needs identified by participants. Some children
with special needs have a genetic predisposition that will not
allow them to breastfeed.
Conclusion: Breastfeeding is a public health issue. There is
a significant opportunity to positively impact maternal and
child health outcomes now and throughout the life course by
increasing breastfeeding initiation and duration rates among
mothers who have children born with special health care
needs. Recommendations include designing workshops,
BFIC Abstracts 621
trainings, and materials that specifically address supporting
mothers who have CSHCN to breastfeed, including creating/
redesigning academic curricula that trains future profession-
als on breastfeeding in CSHCN.
Substance Use Disorder, Mental
Healthm and Racism: Breast/
Chestfeeding and Incarceration
Paynter, M. J.
Dalhousie University School of Nursing, Halifax, Nova
Scotia, Canada
Background: This workshop refers to research and prac-
tice in Canada to frame a discussion of how substance use
disorder, mental illness, and racism add layers of complex-
ity to the breast/chestfeeding experiences of incarcerated
people. Associated with high rates of childhood trauma,
more than half of all people incarcerated in prisons for
women in Canada report substance use disorder and mental
illness. Most incarcerated pregnant parents will be sepa-
rated from their children and/or restricted in access to the
education, equipment, and support required to pump their
milk. Yet breast/chestfeeding is particularly valuable for
this population. There is an increased probability that the
infants of incarcerated pregnant people experiencing sub-
stance use disorders will experience neonatal abstinence
syndrome (NAS). Skin-to-skin and breast/chestfeeding are
first-line therapy for infants with NAS. As breast/chest-
feeding is a protective factor against peripartum depression
(PPD) and high rates of mental illness put incarcerated
people at greater risk of PPD, parental benefit from breast/
chestfeeding is also compromised. Furthermore, people of
color and Indigenous people are incarcerated at far higher
rates than white people and experience greater barriers to
breast/chestfeeding success. Incarceration magnifies the
“breastfeeding gap” rooted in racism and exclusion and
creates barriers to the therapeutic effects of breast/chest-
feeding for infants and parents.
Aim: Participants in this workshop explore the breast/chest-
feeding experiences of incarcerated people in relation to sub-
stance use disorders, mental illness, and racism.
Narrative: We discussed the current practices for perinatal
care for incarcerated people in the federal and provincial sys-
tems in Canada and contrasted those practices with the expe-
riences of workshop participants from other jurisdictions. For
example, the Mother-Child program in Canada allows chil-
dren up to age 6 to reside with their mothers; in the United
States and the United Kingdom, prison nursery programs
only include children to age 18 months. Carceral administra-
tion and infrastructure create barriers for incarcerated parents
for breast/chestfeeding. Baby-friendly hospital practices
where the incarcerated parents give birth can positively influ-
ence breast/chestfeeding, such as by encouraging skin-to-skin
and breast/chestfeeding for NAS. Some participants in the
workshop shared that not only were incarcerated patients pre-
vented from breast/chestfeeding in their jurisdictions, but
patients are routinely tested for substance, and those who test
positive for any illegal drug are “not allowed to” breast/chest-
feed. Participants expressed moral distress about the restric-
tions on the movement and contact with their infants of
incarcerated people in their care in the postpartum period.
Conclusion: In this workshop, participants discussed prac-
tice norms in their jurisdictions with respect to peripartum
support for breast/chestfeeding among incarcerated people.
Participants discussed how denying parents and infants the
right to a breast/chestfeeding relationship risks infringing
civil and human rights and can cause moral distress for care
providers. Participants in the workshop gathered valuable
tools and innovative ideas for advocacy to practice change in
their jurisdictions.
The Public Health Breastfeeding
Pyramid: Deconstructing Barriers in
the Community
Sankofa & Reis-Reilly, H. N.
National Association of County and City Health Officials,
Washington, DC, USA
Funding: Centers for Disease Control and Prevention
Background: Breastfeeding promotion and support efforts
focused on individual families are critical for increasing
knowledge and self-efficacy. However, successful and sus-
tainable initiatives must include community-wide strategies
that recognize, challenge, and seek to deconstruct the struc-
tural barriers to breastfeeding that disproportionally compro-
mise the capacity of low-income and minority families to
breastfeed at levels recommended by health professionals.
Utilizing lessons learned from supporting 72 community
demonstration initiatives through the Reducing Breastfeeding
Disparities Through Peer and Professional Support Project,
the National Association of County and City Health Officials
(NACCHO) tailored the Public Health Impact Pyramid to
focus on breastfeeding. NACCHO’s Public Health
Breastfeeding Impact Pyramid (Figure 2) presents the multi-
level factors that influence community and individual breast-
feeding behaviors and outcomes in the United States.
Purpose: Front-line service professionals working in dis-
tressed communities are disheartened by low breastfeeding
rates among clients in their programs and often think of
622 Journal of Human Lactation 34(3)
breastfeeding as an individual mother’s choice, not a public
health issue of collective responsibility. The goal of the
workshop was to increase awareness among community-
level lactation service providers of the systemic and struc-
tural barriers to breastfeeding that affect those they serve.
Those barriers are outside of parents’ sphere of power to
solve. Workshop attendees identified breastfeeding barriers
and aligned them to the differing levels of the pyramid.
Further, attendees reflected on the breastfeeding promotion
and support strategies they currently implement and ascer-
tained that the much of their efforts focus on the upper two
levels of the pyramid. Through discussion, there was an
agreement that there is a need to expand efforts to include
strategies that tackle the crosscutting issues at the lower
pyramid levels if community-wide shifts in breastfeeding
behavior and attitudes are to take place.
Narrative: The policies and systems that shape our envi-
ronment affect the availability and accessibility of health
care and affect individual capacity to implement recom-
mended health behaviors. Attendees were introduced to the
Policy, System, and Environmental (PSE) change approach
as a mechanism to implement changes within their own ser-
vice environments by creating sustainable organizational
shifts that can positively affect health outcomes at the com-
munity and population levels. The PSE change approach
creates an opportunity to shift the context (blue tier of the
health impact pyramid) to make the healthy behavior an
easy, default option for families. Implementing supportive
policies and systems to create breastfeeding-friendly envi-
ronments helps increase breastfeeding rates. NACCHO
shared the Breastfeeding Public Health Impact Pyramid and
discussed how successful community projects identified and
addressed policies, practices, and destructive interventions
for the families in their communities.
Conclusion: While community-level health programs are
often responsive to downstream health issues by working at
the upper levels if the pyramid, PSE changes seek to address
upstream structural or systemic barriers that lead to poor health
outcomes. Implementing PSE changes in community-level
breastfeeding interventions helps change the context by creat-
ing breastfeeding-friendly agencies and communities.
Unpacking Emergency Response From
2017: Infant Feeding in Puerto Rico
Santaballa, L., & Morales Y. C.
Alimentacion Segura Infantil, Dorado, Puerto Rico
Background: In September 2017, Category 5 Hurricane
Maria ripped across Puerto Rico. The majority of the popula-
tion lost electricity, and widespread food and gasoline short-
ages developed quickly. In the week after the storm, human
milk stashes were fully defrosted and dumped down the
drain, electric breast pumps could not be operated, relief
lines could take more than 10 hours to navigate, only 30% of
roads and highways were fully functional, and breastfeeding
was often abandoned. Relief efforts were slow to arrive, and
it took more than three weeks for less than 50% of stores and
government offices to begin to open. It is projected that 30
babies were born per day during the storm and through the
recovery period.
Narrative: Infant and young child feeding was not a part of
public policy or treated as a priority health issue, and dona-
tions of powdered infant formula were branded and distrib-
uted without breastfeeding counseling or safer feeding
instructions. Based on “Health Concerns of Women and
Infants in Times of Natural Disasters: Lessons Learned From
Hurricane Katrina,” we anticipate that Puerto Rico will expe-
rienced elevate rates of preterm babies, low birthweight, and
very low birthweight. Without access to clean water, infant
formula preparation was extremely difficult and continued to
put infants at additional risk. About a month after Maria, I
founded Alimentacion Segura Infantil (ASI)—ASI means
“this or that.” A freestanding infant feeding support clinic
was not feasible in conditions of widespread road blockages
and gas shortage; hence, ASI recruited 10 volunteers from
across the island to serve underserved and marginalized fam-
ilies. We are training this core group to be Infant and Young
Child Feeding Specialists in Emergencies (IYCF-E) with the
WHO/UNICEF curriculum and in a culturally specific
breastfeeding counselor course. We traveled the island doing
4-hour community-based IYCF-E training accompanied by
lactation clinics. We work with families regardless of how
they are feeding their babies and talk about breast/chestfeed-
ing, human milk feeding, and using formula. It is necessary
to talk about all of these in order to save lives and reduce the
risks of illness.
Figure 2. National Association of County and City Health
Officials breastfeeding public health impact pyramid.
BFIC Abstracts 623
Conclusion: Our community-based organizing efforts
recognize that social equity creates food stability; hence
our work focused on equity, humane treatment of all infant
and young child feeding choices, with an emphasis on
IYCF-E as a health issue and using community-based
resources. This model is one that can be replicated in other
places when we cannot rely on outsiders to respond imme-
diately. Within the next year, we hope to be providing spe-
cialized training to the community so we can become a
peer counselor organization and our volunteers can accrue
hours to become lactation consultants. We are seeing
enough families so that IBCLC mentoring under Pathway
3 is a possibility.
It’s Not About the Milk: The Donor
Milk Recipients’ Experiences, Maternal
Identity, and the Implications for
Breastfeeding Promotion
Sargeant, J. J.1
1Zurich, Switzerland
Background: There can be a celebratory atmosphere when
parents in need obtain donor milk and are able to feed their
baby a diet exclusively of human milk. When the baby is
healthy and people believe that the mother has achieved her
goal, social support may be reduced or cease altogether. For
many women, however, wanting to breastfeed is not about
the milk but about the relationship and the act itself. It is
about maternal and feminine identity.
Purpose: We need to explore the psychology of those
whose bodies are unable to provide milk sufficient to enable
their babies to thrive and tell their stories. We need to
include these emotive experiences in our discussions and
explore ways to protect the mental health of new mothers
while continuing the vital work of promoting and support-
ing breastfeeding. This discussion session allowed for an
exposè of many of these stories and explored the implica-
tions and possible directions that breastfeeding promotion
could take.
Narrative: When mothers are unable to breastfeed in the way
that they hoped, they may be met with feelings of inadequacy
and must then move through a grieving process for the loss of
a perceived relationship. Many mothers in search of donor
milk do so because they are experiencing this sense of loss
and/or guilt at being unable to exclusively breastfeed, and
there remains hope that donor milk will help to move them
toward a path of healing. When we explored the experiences
and the beliefs of donor milk recipients, along with feelings of
distress before and after using donor milk, it became apparent
that for many mothers, using donor milk did not heal their
pain. For many, exposure to a peer with an abundant supply of
milk magnified their insecurities. Research and conversations
with donor milk recipients can help us to realize the degree in
which breastfeeding is often vitally connected with maternal,
feminine, and personal identity. Their own awareness of their
reasons for wanting to exclusively breastfeed often surfaced
only when they recognized that using donor milk did not heal
their pain. These women are in need of empathetic, continued
postnatal support. Lactation supporters and consultants can
work to normalize at-breast supplementation as a way to foster
breastfeeding relationships irrespective of milk supply.
Unfortunately, exposure to this feeding method is not described
in breastfeeding promotional campaigns.
Conclusion: We need to explore ways that breastfeeding
promotion can be beneficial while not being destructive to
the psychological well-being of donor milk recipients. We
must continue to offer them choices and support, and promo-
tion must begin treating breastfeeding as a relationship,
instead of solely as a nutritional product, while remaining
attentive to the psychological implications of the loss of this
relationship. We must continue to look at ways to promote
breastfeeding so that we protect maternal well-being and
normalize the array of breastfeeding options that exist, such
as at-breast supplementation and pumping. We must recog-
nize the importance of continued care for all mothers, past
early days postpartum, and provide options that enable them
to achieve the relationship they desire.
Breastfeeding, Chestfeeding, Lactation,
and LBGTQ+
Scott, L. G.
Baptist Health Lexington, Lexington, KY, USA
Background: Many organizations in the United States and
around the world are working tirelessly to promote, sup-
port, and protect breastfeeding, particularly in health dis-
parity groups. The LBGTQ+ community is one population
classified under the umbrella of health disparities. Human
lactation and the social-emotional benefits of breastfeed-
ing/chestfeeding are often not explained to families who
identify as LBGTQ+, nor is inclusive language used when
this topic is discussed. Chestfeeding is an inclusive term to
refer to transmasculine or gender-nonconforming individu-
als and the act of feeding an infant at the chest with or with-
out supplementing tube.
Aim: To bring awareness of the many options for breast-
feeding/chestfeeding for LBGTQ+ families. These options
include inducing lactation through childbirth, inducing lacta-
tion without birthing, using supplemental nursing systems to
nourish his/her/their child, or a combination of these to meet
the nutritional needs and family’s goal.
624 Journal of Human Lactation 34(3)
Narrative: The LBGTQ+ community is one population
classified under the umbrella of health disparities. Many
health care providers do not feel comfortable gathering
case histories and providing services for members of the
LBGTQ+ community. LBGTQ+ community members also
are hesitant to seek out medical assistance or ask questions
for fear of being judged or not treated with respect. In addi-
tion to being at risk for not having basic health care needs
met, LBGTQ+ couples choosing to start a family are often
not aware of their options regarding nourishment for their
child with human milk and/or breastfeeding/chestfeeding.
Furthermore, limited, if any, research is available on induc-
ing lactation in the LBGTQ+ community, LBGTQ+ breast-
feeding/chestfeeding in terms of meeting the Center for
Disease Control (CDC) goals, or social/emotional benefits
for the LBGTQ+ family unit. When a LBGTQ+ family
chooses to nurse, the family often does not receive the
needed support through peer support groups, lactation con-
sultants, and health care services.
Conclusions: In theory, many options are available for
LBGTQ+ families in regard to lactations and supplementa-
tion with donor human milk. However, these theories have
limited, if any, bodies of low-level research. At least a handful
of IBCLCs demonstrate willingness and cultural sensitivity to
support LBGTQ+ families through education, promotion,
and support of lactation and feeding at the breast/chest. The
scope of practice of an IBCLC is large, thus the participants
identify that not all IBCLCs can specialize in human lactation
within the LBGTQ+ community. When lactation is induced
through pharmaceutical means, limited research is available
on the effectiveness and safety for both the parent and child.
A strategic plan in supporting the LBGTQ+ community in
meeting each family’s lactation and breastfeeding/chestfeed-
ing goals is the next step needed. This plan needs to include
guidelines for LBGTQ+ families in finding services, advanced
level training completed by IBCLCs, and a plan for complet-
ing research to further develop evidence-based practice.
Mobilizing a Large Integrated Health
Care System Toward Improved
Workplace Breastfeeding Support
Scott, V. C.1, & Taylor, Y. J.2
1University of North Carolina at Charlotte; 2Atrium Health,
Charlotte, NC, USA
Funding: University of North Carolina at Charlotte Faculty
Research Grant, Center for Outcomes Research and
Background: Although national breastfeeding rates have
improved across recent decades, women continue to face sig-
nificant barriers to achieving their breastfeeding goals.
Returning to work is a critical transition with known impacts
on breastfeeding duration and intensity. Evidence suggests
that both employees and employers can benefit from provid-
ing a supportive environment to help mothers prolong breast-
feeding after returning to work. However, great variability in
support exists across organizations. This issue is especially
salient in health care settings where women of childbearing
years make up a large percentage of the workforce.
Purpose: The Carolinas Healthcare Employee Breastfeeding
Study (CHEBS) is an interdisciplinary collaboration between
researchers and human resources personnel that seek to under-
stand the experiences of workplace support for breastfeeding
among health care employees, identify factors that influence
breastfeeding after returning to work, and inform programs
and policies to improve workplace lactation support.
Narrative: We used a mixed-methods research approach
that involved surveys and focus groups to surface workplace
breastfeeding issues and potential solutions to existing chal-
lenges. A literature review guided the development of a sur-
vey to answer questions of interest. The Employee Perceptions
of Breastfeeding Support Questionnaire (EPBS-Q) was used
to measure breastfeeding support. Additional questions were
used to measure job satisfaction and collect basic demograph-
ics. We invited employees in a large health care system
located in the Southeastern United States to complete the
online survey via intranet postings, email, and in-person
recruitment. Those completing the survey (N = 915) were
invited to participate in one of five focus groups (n = 35).
Most respondents were female (85%) and worked in clinical
settings (56%). Only 16% had breastfed in the past 3 years.
Overall perceptions of workplace support for breastfeeding
were higher among employees without recent breastfeeding
experience and lower among those with recent breastfeeding
experience. Perceptions of support via having a private space
to pump were low for all employees, regardless of breastfeed-
ing experience. Employees who worked in a clinical setting
and breastfed within the past 3 years reported lower breast-
feeding durations than those who worked in nonclinical set-
tings. Focus groups revealed that employees have mixed
experiences with receiving support. Key themes included
the important role of leaders in providing a supportive envi-
ronment for expressing human milk at work, the need for
policies to reduce variation in the employee experience, and
the need to educate coworkers about the needs of lactating
employees. Recommendations for action informed by the sur-
vey and focus group were prioritized by the project team
based on feasibility and resource need. The most feasible
interventions included providing updated information on the
location of lactation rooms, starting an employee breastfeed-
ing support group, and recommending policy change.
Conclusions: Despite a focus on improving health, health
care settings may face unique challenges in their efforts to
provide workplace lactation support for their employees.
BFIC Abstracts 625
These challenges may be greater for employees involved in
direct patient care. A process for data collection and prioriti-
zation can inform an incremental approach to improving the
experience for breastfeeding mothers and help them achieve
their breastfeeding goals.
The Constraints of Exclusive
Breastfeeding in Efoulan Health District
of Yaounde Cameroon, Sub-Saharan
Tambe A. B.1,2, Roger B. M.1, Ashu N. J.3, Christian B. B.1,
Emilienne N. C.1, Nanfack P.1, Celine M. S.1, Anne N. C.1, &
Nzefa, L. D.4
1Institute of Medical Research and Plant Medical Studies,
Yaoundé, Cameroon; 2Wealth Creation Foundation (WCF),
Yaoundé, Cameroon; 3Facilty of Health Science, University
of Buea, Buea, Cameroon; 4Faculty of Medicine and
Biomedical Sciences, Department of Public Health Yaoundé
University, Yaounde, Cameroon
Background: Breastfeeding provides infants with superior
nutritional content that can improve infants’ immunity and
possible reduction in future health care spending. But the
majority of infants are not exclusively breastfed as recom-
mended by World Health Organization.
Aim: To determine the constraints of exclusive breastfeed-
ing practices among mothers in Efoulan District, Cameroon.
Narrative: This hospital-based cross-sectional study was
conducted among mothers (N = 230) with under 5 infants
during postnatal consultation at the various health structures
of Efoulan health district. Data collection was done using a
pretested, interview-led questionnaire. Multivariate logistic
regression models that adjusted for confounders were carried
out to determine association between breastfeeding initiation
(colostrum intake) and exclusive breastfeeding (EBF) and
their determinant factors. The rate of colostrum intake and
exclusive breastfeeding among under 6 months infants was
89.1% [95% CI, 84.4%-92.8%] and 44.4% [95% CI, 35.4%-
53.5%], respectively. After adjusting for potential confound-
ers, multivariate analyses revealed four factors, marital status
(adjusted odds ratio [AOR] = 4.13, 95% CI, 1.01-16.86),
income level (AOR = 3.42, 95% CI, 1.43-8.19), parity (AOR
= 6.05, 95% CI, 1.51-24.22), and maternal knowledge of
diarrhea (AOR = 0.02, 95% CI, 0.00-0.11), as determinants
of breastfeeding initiation (colostrum intake), while four,
marital status (AOR = 4.75, 95% CI, 2.42-9.32), income
level (AOR = 1.61, 95% CI, 1.01-2.58), maternal age (AOR
= 0.24, 95% CI, 0.13-0.47), and sex of index infants (AOR =
0.47, 95% CI, 0.26-0.86), were determinants of EBF.
Conclusion: We recommend that efforts should be invested
on improving maternal level of education, income, nutri-
tional counseling, and access to maternal health services in
order to significantly increase the rate of exclusive breast-
feeding and to attain the fourth Sustainable Development
Sexual Assault Survivors and
Breastfeeding: Biopsychosocial
Mechanisms for Exploring Infant
Feeding Decision Making and
Tello, H.
University of Massachusetts Lowell, Lowell, MA, USA
Background: Sexual trauma histories are associated with
acute and chronic health problems salient to perinatal experi-
ences, particularly in the context of infant feeding. Trauma
research indicates that there are several variables that moder-
ate the relation between the effects of sexual trauma and their
impact on breastfeeding experiences. Existing literature
describes the psychosocial and physiological outcomes, risk,
and protective factors of sexual assault. Survivors often
experience psychological effects, including: (a) PTSD, (b)
mood disorders, (c) decreased self-esteem and self-efficacy,
and (d) difficulty with attachment. Behavioral affects have
also been reported, including dysfunctional care-seeking and
increased risk behaviors. Physiological effects of sexual
trauma are also well documented (e.g., disruptions in endo-
crine functioning contribute to physiological symptomol-
ogy). These influences are also related to breastfeeding
outcomes and experiences.
Narrative: It is critical to understand the effects of sexual
assault in this context to predict infant feeding decision mak-
ing and outcomes, yet a profound dearth of research on the
specific pathways of these relationships persists. My project
explores the role of psychological processing of sexual
assault as a factor in the experience of infant feeding as either
contributing to retraumatization or posttraumatic growth.
Using a narrative identity framework, this project explored
the impact of complete or incomplete narrative processing of
traumatic experiences on breastfeeding experiences and
Conclusion: Improvement in trauma-informed care pre-
vents retraumatization during the infant-feeding experience
as well as empowers caregivers to support their clients’
efforts to utilize supportive perinatal care as an opportunity
to process traumatic experiences as a strategy for posttrau-
matic growth.
626 Journal of Human Lactation 34(3)
The Invisible Breasts
Ubbe E.1
1Photographer, Registered Nurse Midwife, Stockholm,
Funding: This project was originally funded by Amning-
shjalpen and Sensus through the project Breastfeeding Courses
for Expectant Parents.
Background: The Invisible Breasts is an exhibition (42 pic-
tures) and a photo book (bilingual English/Swedish). It
started as a resistance project in 2013 after noticing that
Swedish women who breastfed in public were beginning to
be harassed. I realized there had been a shift in society, and
more control was put on women compared to when I was a
child, when everybody was topless on the beaches and public
swimming centers. I never thought that being topless on the
beach would be a strange thing (though I know things are
different in the United States and in many countries), and I
remember being topless together with my mother and grand-
mother, who were also topless. I understood that something
is shifting; little girls have become ashamed of taking show-
ers with their classmates after gymnastics at school, Swedish
breastfeeding rates are decreasing, and “beauty surgeries”
are increasing. This shift is, I think, dangerous in a bigger
way than the right to be able to breastfeed wherever a woman
and child wants to. I see a connection to the right winds that
are growing in the world and also the idea of who can be in
public space and what kind of pictures shape our ideas of
what women are and how they should look.
Purpose: In The Invisible Breasts, I have asked the women to
pick a situation where they would normally breastfeed and
made the picture in that situation. I have also asked women to
pick an everyday situation where they would normally be
dressed and made a picture there but topless. The situations
vary from breastfeeding while bicycling or in the shopping
mall, to cooking dinner topless at home, or being topless in the
subway. Every picture has its own story, and when I give artist
talks, people get very involved, whether they like the work or
not. I believe that these talks create an opportunity to raise
awareness on how women are shown in media, how this
affects us, and of how control of women can slowly grow. The
images are a way to claim (reclaim?) the space for normally
looking women’s bodies and breastfeeding in the public space.
During every opening, I invite the visitors to have their own
picture taken and become a part of the show, with the goal to
make a new book with 10 times the pictures (Figure 3).
Conclusions: The Invisible Breasts has now been shown in
eight exhibitions around the world. The collection is steadily
growing, and through every show, including the BFIC 2018,
I see that there is a need for these kinds of images and
narratives. When I meet women during the shows, I sense
that there is a connectedness in this experience that needs to
be highlighted and prioritized. Our experiences need to be
recognized and valued.
The “Unique Families Program” (UFP):
Maximizing Neutral Compassionate
Vahle, R., & Weber, D.
Family to Family Support Network’s Unique Families
Program, St.
Luke’s Medical Center, Boise, ID, USA
Background: What constitutes the definition of family in
the unique family population is often very different from the
“traditional” family. With the changes in how families are
created and the diversity in family structure on the rise, it is
increasingly imperative that health care systems consider new
processes to care for the unique family population. Currently,
there are inconsistent approaches to care for the unique fam-
ily, communication and language barriers due to lack of
workforce knowledge, and confusion from the workforce on
their role. Furthermore, health care system biases, insensitive
care and language, and societal stereotyping toward those of
Figure 3. From The Invisible Breasts by Elisabeth Ubbe.
BFIC Abstracts 627
differing beliefs, culture, age, sexual orientation, and nontra-
ditional family structures are creating unequal access and a
lower quality of care for these unique families. These con-
cerns have demonstrated a need and opportunity to enhance
the quality and value of unique family health care, leading to
the development of a standardized care model for unique
families utilizing obstetric care.
Research Aim: To address the need and fill the gap, Family
to Family Support Network (FFSN) created the Unique
Families Program (UFP).
Narrative: The Unique Families Program Approach: The
UFP is a comprehensive, hospital- based, training program
that has been fine-tuned over the past 10 years. Its mission is
to transform the health care culture and services to be “unique
family sensitive” system-wide. The model utilizes an inte-
grated, patient-centered approach that enabled and empow-
ered health care professionals to provide comprehensive,
consistent, neutral, and compassionate care to unique families
utilizing obstetric care throughout pregnancy, delivery, and
post-delivery, from adoption and surrogacy arrangements,
incarcerated patients, socially complex families, refugees and
immigrants to those struggling with critical issues and needs
(e.g., substance use disorder, sexual assault, and domestic
violence). It utilizes three critical training components that go
beyond simple classroom training for professionals to impact
all hospital systems and reach beyond the hospital to educate
the hospital’s many community partners. The three compo-
nents are (a) the Unique Families Training Seminars, (b)
Community Resource Connection, and (c) Internal Healthcare
Infrastructure Development. While classroom training is an
absolutely critical component of change, FFSN has learned
that a limited number of staff attending training can never be
enough to make institutional change. It is critical to have hos-
pital-wide commitment. Hospital-wide commitment means
more than administrators allowing staff to participate in train-
ing. Hospitals agree to make systemic changes that will set up
staff to succeed and make meaningful outreach to community
partners so that hospital staff can trust community partners.
Conclusion: The UFP model is successful. The three core
components work together to improve hospital staff sensitiv-
ity, understanding, and skills necessary to better serve
expectant parents; harness the power of the health care team;
and build UFP compassionate care infrastructure by updating
hospital policies, guidelines, and workflows.
Multidisciplinary Approach to Diagnosis
and Treatment of Breastfeeding Pain
Valentine, A. D., & Scott, L. G.
Baptist Health Lexington, Lexington, KY, USA
Background: The project began with consistent complaints
from breastfeeding persons’ report of pain affiliated with
breastfeeding and/or pumping that was not being managed.
Multiple families were approaching us as combination SLP/
IBCLC after being treated by multiple practitioners in the
clinical world.
Purpose: To develop a multidisciplinary approach to evalu-
ation and treatment of breastfeeding difficulties and manage-
ment of said difficulties.
Narrative: Previously in breastfeeding history, difficul-
ties were addressed significantly by local lactation care
providers. Often this becomes difficult if there are no lac-
tation specialists in the area or limited practitioners.
Working in an urban hospital, the patients that are being
provided services often travel from distances to receive
care. As an SLP, it became evident that people were not
receiving the assistance they needed to become successful
breastfeeding dyads/families. Often, the worst culprit was
pain management. Breastfeeding persons would complain
of pain without achieving a solution to the problem. During
the evaluation process, the infant and mother were both
evaluated during breakdown of the breastfeeding pair,
including: infant latch, mother’s breasts, mother’s milk
supply, pain (scale, description, etc.), and other feeding
methods. A thorough oral mechanism exam was performed
on every infant. Often, oral restrictions were identified as
etiology of mother’s reported pain. However, as more
patients were identified, it became evident that there were
often larger issues, including wound management for nip-
ple pain. During this time, physical therapy wound care
was invited to begin evaluating mothers with nipple abra-
sions/wounds and so on. The process leads to the develop-
ment of an interdisciplinary team for breastfeeding and
breast pain management.
Conclusion(s): While this initial project began as breast
pain management, it became the development of an inter-
disciplinary team for breastfeeding success. Throughout
group discussions, clinical practice observances, as well
as reports from families, a team approach was determined
as the most effective systematic method for improvement
of successful breastfeeding as well as decreasing pain
symptoms. It was determined that possible candidates for
this multidisciplinary team included: SLP, IBCLC, nurs-
ing leaders or other pediatric nursing staff, social workers,
occupational therapists, physical therapists, wound care
physical therapists, physicians, families, supply managers
for facility, directors (for possible program development),
and chaplain. The development was designed to reach out
to colleagues in the facility to determine what role and
what interest in participation could be included in the
development of this team.
628 Journal of Human Lactation 34(3)
Cultural Attitudes, Women’s
Experiences, and Breastfeeding Beyond
the First Year
Weaver, J. M., & Grassley, J.
Boise State University, Boise, ID, USA
Background: The World Health Organization and Health
Canada recommend sustaining breastfeeding until 2 years
old and beyond. Guidelines in the United States are vague.
The American Academy of Pediatrics recommends breast-
feeding a minimum of 1 year and then as long as mother and
child are mutually satisfied. The Centers for Disease Control
and Prevention stop gathering data about breastfeeding rates
after 12 months. Women who choose to breastfeed their chil-
dren beyond a year often find themselves negotiating cul-
tural attitudes about the “appropriate” duration for
breastfeeding, a lack of evidence about the bio-psychosocial
benefits of breastfeeding beyond infancy, and their desire to
continue breastfeeding.
Purpose: To explore the intersection between cultural atti-
tudes and women’s experiences of breastfeeding beyond
infancy through both qualitative and quantitative research.
Narrative: The intended goal of this discussion was to dia-
logue about the ways lactation, women’s bodies, and culture
interact in women’s decisions to nourish and nurture their
children by breastfeeding beyond a year. To identify cultural
attitudes, we discussed findings from a survey study of
undergraduate college students’ responses to images show-
ing different-aged children breastfeeding. The purpose of
this study was to determine whether students’ acceptance of
breastfeeding changed as a child got older and what their
intentions were about breastfeeding at increasingly older
ages. Women’s breastfeeding stories collected using qualita-
tive methodology also provided examples of women’s expe-
riences. The purpose of this study was to explore maternal
breastfeeding confidence through asking women to tell a
story they would never forget about breastfeeding one of
their children. Two women told stories about breastfeeding
an older child. In the survey study, college students’ responses
reflected current cultural attitudes about breastfeeding
beyond infancy. They viewed breastfeeding toddlers as
embarrassing to watch and as something inappropriate and
without benefit to the child. Furthermore, their intentions
about breastfeeding older children were much weaker than
their intentions to try breastfeeding or to breastfeed in early
infancy. In qualitative work, women’s stories described the
lack of support they experienced when breastfeeding beyond
a year. Because the written and verbal messages they received
from reading available information and their health care pro-
viders did not support breastfeeding their older child, they
stopped discussing it with their pediatricians.
Conclusions: Current cultural attitudes do not support
women who decide to breastfeed beyond infancy. To avoid
social stigma, mothers often avoid breastfeeding their older
child in public, which perpetuates negative cultural attitudes.
Strategies for supporting women and changing cultural atti-
tudes need to be developed.
Maternal Positive Emotions During
Infant Feeding and Breastfeeding
Wouk, K., MS1, Tucker, C. M.1, Pence, B. W.2, Meltzer-
Brody, S.3, Zvara, B.1, & Stuebe A. M.1,4
1Department of Maternal and Child Health; 2Department of
Epidemiology, Gillings School of Global Public Health;
3Department of Psychiatry; 4Department of Obstetrics and
Gynecology, University of North Carolina School of
Medicine, Chapel Hill, NC, USA
Background: Major medical organizations in the United
States recommend exclusive breastfeeding for 6 months,
with continued breastfeeding through the first year “or lon-
ger as mutually desired by the woman and her infant.” Few
studies have explored the role of maternal emotions in
breastfeeding outcomes. Dr. Barbara Fredrickson’s broaden-
and-build theory of positive emotions suggests that experi-
ences of positive emotions lead to adaptive benefits by
broadening one’s thought-action repertoire, allowing the
accrual of personal and social resources to improve health
and well-being.
Aims: To estimate the association between maternal positive
emotions during infant feeding at 2 months and time to any
and exclusive human milk feeding cessation and overall
maternal evaluation of breastfeeding at 12 months.
Narrative: Women (N = 185) from a longitudinal cohort of
mother-infant dyads were followed from the third trimester
through 12 months postpartum. All women intended to
breastfeed at least 2 months. We measured positive emotions
during infant feeding at 2 months using the mean subscale
score of the modified Differential Emotions Scale (mDES).
The mDES asks the “greatest amount” 10 positive and 10
negative emotions were experienced during infant feeding
over the past week using a 5-point Likert scale. We used Cox
proportional hazards regression to estimate hazard ratios for
time to any and exclusive human milk feeding cessation asso-
ciated with a one-unit increase in positive emotions. We also
estimated the association between positive emotions and the
maternal evaluation of breastfeeding at 12 months using the
Maternal Breastfeeding Evaluation Scale (MBFES), which
asks about agreement or disagreement with 30 statements
about breastfeeding and/or expressing milk as an overall
BFIC Abstracts 629
experience using a 5-point Likert scale. A one-unit increase in
positive emotions at 2 months was associated with a 26%
lower hazard of stopping any human milk feeding and 42%
reduced hazard of ceasing exclusive human milk feeding
(Table 1). The association with human milk feeding cessation
was stronger where women had met their prenatal breastfeed-
ing intention at 2 months and among non-Hispanic white
women, while the association with exclusive human milk
feeding cessation was stronger among women of color.
Positive emotions at 2 months were also associated with a
better maternal report of the overall breastfeeding experience
at 12 months, with a stronger association among women who
were human milk feeding at 2 months. Positive emotions at 2
months were more strongly associated with the maternal
enjoyment and role attainment subscale of the MBFES.
Conclusions: Positive emotions during feeding at 2 months
were associated with a longer time to cessation of any and
exclusive human milk feeding. More research is needed to
understand trajectories of maternal emotions during infant
feeding and maternal and infant outcomes associated with
positive emotions.
Table 1. Hazard Ratios for Breastfeeding Cessation Associated With a One-Unit Increase in Positive Emotions (N = 185).
Variables nCrude Weighted
Any human milk feeding (HMF)
Among all women HMF at 2 months 172 0.85 (0.62, 1.16) 0.74 (0.53, 1.02)
By prenatal breastfeeding intention
Intention met at 2 months 125 0.70 (0.46, 1.07) 0.56 (0.36, 0.87)
Intention not met at 2 months 47 1.52 (0.93, 2.48) 1.40 (0.82, 2.41)
By race/ethnicity
Non-Hispanic white 130 0.72 (0.50, 1.03) 0.61 (0.41, 0.89)
Black, Hispanic, other race/ethnicity 42 1.18 (0.59, 2.34) 1.03 (0.50, 2.16)
Exclusive human milk feeding (EHMF)
Among all women EHMF at 2 months 114 0.62 (0.36, 1.07) 0.58 (0.34, 0.98)
By race/ethnicity
Non-Hispanic white 94 0.78 (0.53, 1.13) 0.63 (0.44, 0.91)
Black, Hispanic, other race/ethnicity 20 0.23 (0.08, 0.66) 0.31 (0.11, 0.91)
Note: Models weighted to control for confounding by maternal antenatal attachment score, prenatal depression score, adult attachment style, birth
trauma, number of breastfeeding problems in the first 2 weeks, return to work by 2 months, and negative infant temperament.
Maternal Autonomy and Challenges of
Consent in Mothers Who Experience
the Phenomenon of Breastfeeding/
Nursing Aversion and Agitation: When
Breastfeeding Triggers Negative
Emotions and an Internal Ethical
Yate, Z. M.
Vice Chair, London Research Ethics Committee, Health
Research Authority.
Committee member, Research Ethics and Governance,
King’s College London, London, UK
Background: Breastfeeding or nursing aversion and agita-
tion (aversion) is a phenomenon some women experience
whereby breastfeeding triggers negative emotions such as
anger or agitation and certain intrusive thoughts like feeling
trapped or wanting to run away, coupled with the overwhelm-
ing “urge” to de-latch. Aversion can happen to any woman, at
any point in their breastfeeding journey—with varying onset,
duration, and severity. The prevalence and cause is not yet
known—though it is not thought to be a medical condition,
like dysphoric-milk ejection reflex. Autonomy is a key con-
cept in biomedical ethics, the heart of any health care practi-
tioner’s work when treating or supporting patients, and
critically important for any person’s personal well-being.
Understanding autonomy needs to consider agency, control,
and decision making—all of which are arguably compro-
mised when experiencing breastfeeding aversion.
Purpose: The lived experience of breastfeeding for those
who get negative feelings is rarely highlighted and chal-
lenges the typical oxytocin filled, happily-in-love breast-
feeding sessions that media and social media often portray.
This workshop and discussion offers insight into the experi-
ence of compromised autonomy in mothers with aversion.
Narrative: Autonomy is commonly understood in refer-
ence to an individual’s ability to consider their own welfare
and make decisions accordingly. And while a person is
almost always sovereign over their own body, they are also
responsible for their infant as infants cannot autonomously
make decisions or act on them. For mothers, a definition of
630 Journal of Human Lactation 34(3)
autonomy would need to include two persons at least, and
this interplay is not yet fully understood when it comes to
breastfeeding. The concept of maternal autonomy lacks
clear understanding in the literature, and there is little work
on the “act” of breastfeeding—on independent decision
making, agency, and ethical reasoning. Feminism ethics
may help with this with the concept of relational autonomy,
looking at agency in a holistic approach that includes oth-
ers. A key trigger to having aversion is feeling “touched
out”—a phrase commonly used by mothers when they feel
saturated by the constant physical contact required by
breastfeeding and “mothering.” Not having full autonomy
of their bodies, not always feeling like they consent to be
touched, and not having control or a way of stopping breast-
feeding sessions can be overwhelming. Responsive parent-
ing, both day and night, coupled with breastfeeding and/or
bed sharing as a primary caregiver means you cannot just
stop breastfeeding or leave the room.
Conclusion: Aversion illustrates why autonomy could be
compromised as aversion can create a complex conflict in
the dyad, namely, the competing considerations of an infant’s
need to breastfeed and a mother’s rational desire to breast-
feed/continue to breastfeed with the “negative” feelings
experienced while breastfeeding and the overwhelming
“urge” to de-latch. This dilemma is experienced with those
struggling with aversion and is challenging to navigate, caus-
ing many levels of emotional difficulty, including stress,
guilt, and shame. De-latching can sometimes be the only way
to cope, but this causes upset for both parties, and if the
infant is under 12 months, alternative action for life-sustain-
ing nutrition is required.
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