Breastfeeding - Let's quit judging and start supporting!

The 'Breast is best' understanding that we are attempting to cultivate in our community is such an important one BUT it needs to be done right... it needs to be done in a manner that supports all women who want to do the best by their babies when it comes to feeding them (which, let's face it, is the vast majority of new mothers). Instead, through our efforts to promote breastfeeding we have inadvertently developed a culture of harsh judgment. 

Of course there has always been a sad culture of judgment around breastfeeding because in our society breasts have been sexualised and, therefore, their use for feeding children in public has, by many, somehow been relegated to a perverse and/or offensive act. I, personally, find such a view abhorrent and do my very best to make clear my stance on this, mostly through supporting women who wish to breastfeed, educating others about breastfeeding, and proudly breastfeeding my children in public. 

However, I am also very disturbed that this same sort of ill-founded harsh judgment is dished out to women who want to breastfeed, and try to breastfeed, but can't breastfeed. I've not done the research on this, but I have no doubt that for the huge majority of women who start out breastfeeding but do not carry it on for more than a few weeks, the reasons for giving up are NOT because they no longer wanted to breastfeed. I know of many women who desperately wanted to breastfeed but who ultimately chose to bottle feed within the first couple of months.  Actually, they didn't choose to stop breastfeeding their babies, not unless you consider it a choice when the alternative is to starve your baby (which was what they were essentially told was happening). The reasons the women I know who gave up breastfeeding early on were varied, but all amounted to the same thing... they were unable to adequately produce enough milk to feed their babies sufficiently. To them, there really was no alternative. And rather then being supported through their grief at not being able to carry out this 'most primal of mothering acts', many were instead chastised and punished - deemed guilty of poor parenting, when all they ever wanted was what was best for their child.

The most common reason for giving up breastfeeding early on is due to a 'lack of milk supply'. Many times I have heard women, midwives and other health professionals speak of a 'perceived' lack of supply when discussing milk supply issues (I've used this term myself), inferring that the woman thinks she lacks milk when, in actual fact, she doesn't. For example, a woman who has the pre-conceived idea that newborns only need feeding every three-or-so hours, and whose baby is 'asking' to be fed every hour (sometimes more, and sometimes for very long periods at the breast) may believe that she is not producing enough milk when she actually is; she doesn't realise that the behaviours her newborn is displaying are quite normal and appropriate and, instead, thinks that her baby is starving due to lack of milk. She has a 'perceived' lack of milk, rather than an actual lack of milk.

While there are, no doubt, many cases of 'perceived' lack of milk that lead a woman to give up breastfeeding, I also don't doubt that many women experience an 'actual' lack of milk supply. Although statistically only 5% of women ought to be physiologically incapable of producing enough milk for their babies, I think this figure is in reality quite a bit higher (in Western society, at least). The reason I think this? I believe that women are frequently not given the support they need to enable them to produce enough milk, and they are encouraged to have unrealistic expectations around newborn behaviour... women are too stressed, tired, malnourished and distressed to support their bodies to produce enough milk, and they are unaware of normal newborn behaviours that are important for assisting the production of milk.

Our society sets women up to fail at breastfeeding... then we punish them for being bad mothers. It's wrong, it's cruel, and it needs to change. Let's examine the dual expectations that our society puts on our new, vulnerable mothers:

• We expect her to know how to care for her newborn, but provide her with virtually no training in this field
• We tell her that 'demand feeding' is best, but that her baby should be sleeping through the night by x months of age
• We tell her to rest up to encourage her milk production, but we expect her to clean the house, do the washing, cook the meals, look after her other children, and we allow the father barely any paid leave from work to help support her
• We make it clear that breastfeeding is the only acceptable way to feed her child, but not in public
• We tell her that 'breast is best', but don't offer the financial support her family requires to keep her from having to return to work when her baby is still a baby

As a society we do an extremely poor job of supporting new mums to fulfill the expectations that that same society places on her. And then we blame her for failing to do a good job of parenting.

We are mothers. We are women. We know how to look after our babies and each other, we know what our hearts tell us is best for our families and IT'S JUST SO BLOODY WRONG AND TRAGIC that we are not given the support we need to be the parents we want to be. Our job is the most important job ON EARTH. It is the hardest job and most demanding job imaginable, yet it is the least valued job in our society.

So, to all the women and mothers out there can I make this plea to you... Can we stop judging other women for not parenting the way we believe is best. We don't know what another's journey has been to get to where she is, and kicking her when she is down will do nothing to improve her circumstances. Instead, let's take every opportunity we can to offer our support and encouragement and to right the wrongs of our society. When we educate and guide others, let's try and do our best to do it in a way that is supportive rather than judgmental. Lets make breastfeeding an achievable experience for all women who are capable of it... and for the mother who is not, lets wrap our arms around her and say, "You did your best. You are a wonderful mum."

And to our men out there, we need you to be on our side with this too. We need you to show pride in us when we do our all to nourish your children the best way we know how (including in public... actually, especially in public). We need your practical support, like cooking the meals, preparing our lunch before you leave for work, doing the washing and cleaning, and helping out with the other kids. And we need your emotional support - give us lots of affirmations and regular hugs, and frequently remind us that we are doing an amazing job of nurturing our children. When that pesky great aunt or well-meaning but ill-informed grandmother try and suggest otherwise, please stick up for us and remind them that we know what's best for our baby.

Finally, there are many wonderful, supportive, empathetic, knowledgeable and sensitive midwives, support networks (La leche league is an obvious one here), mothers and fathers out there who do their very best to assist and sensitively guide our struggling new mums. Keep up the great work! And let's do our best to get as many others on board as we can with regard to all this. We play an incredibly important role in the lives of the women and babies who receive our love and support.

Breastfeeding 9 month old Jonah on the ferry to Tiritiri Matangi wildlife sanctuary, and...

...breastfeeding 2 year old Luca at Tiritiri Matangi 

Diary of a Tandem Feeder - Part 4

In previous Diary of a Tandem Feeder blog posts I have written about my experiences of breastfeeding whilst pregnant.  Well, now I can begin to write about tandem feeding as our baby has finally graced us with his presence!

Jonah was born at home on May 8^th by way of a very peaceful and wonderful water birth.  I am still in shock that he is a he (you might recall me referring to him as a her in previous posts such was my conviction that I was carrying a girl) and that he is so small (7lb, 9oz compared to my previous almost 10lb babies).  Jonah took to breastfeeding like a duck to water, a new experience for me as my other two were tongue tied and initially struggled to latch well.  This has been such a blessing!

Before I write of my tandem breastfeeding experiences, I will begin by writing about my last few weeks of solo feeding Luca.  Really my milk supply didn’t seem to change much over the last weeks of pregnancy.  I doubt there was much milk there at all, but Luca was always content to feed long past any significant swallowing could be observed.  In fact, if left to feed for as long as he desired, a feeding session would typically be between 20 and 40 minutes.  I guess feeding for him was more about the snuggles and closeness than it was about the milk.

Near the end of my pregnancy Luca got into the habit of waking early (between 5am and 5.30 – too early!) and coming into bed with his Mum and Dad to have one of his long comfort feeds.  At the end of this feed his Dad would bring him out to the lounge leaving me to rest for a while.  If we ever tried to rush Luca off the breast he would complain fiercely.  I was a bit worried that this was setting us up for battles when the baby arrived, but ultimately took the attitude that we would deal with that at the time and that Luca and I might as well enjoy these sweet pleasures while they lasted.

Apart from that morning feed, Luca would also be fed off to sleep for his daytime sleep (a process that typically lasted 25 – 30 minutes) and would have a feed before his bedtime.  He consistently had those three feeds on a daily basis and there would be any number of feeds in between those times depending on Luca’s mood and needs.  During the last weeks of my pregnancy I didn’t put any limits on Luca’s frequency, or length, of feeds.  I figured that after the baby was born and my milk came in, Luca’s time at the breast would decrease quite dramatically owing to the fact that he would fill up with milk rather quickly.

Leading up to Jonah’s birth I became quite nervous about how Luca would be during the actual birth.  If I birthed at night as I had done with my other two, my birth sounds might wake him as he is a very light sleeper.  My Mum had been assigned the role of ‘Luca’s carer’ during the birth and I knew she would do whatever she could to keep him happy, but if I could hear him crying I would find that distressing and distracting.  I contemplated the idea of having him at the birth though quickly decided that that would be a foolish move.  He would no doubt want to feed and, for me, during labour that most certainly would not be an option.  Also, at his young age (17 months) I really didn’t see much benefit for him being at the birth of his baby brother.  Big sister Laura (aged 9), on the other hand, wasn’t going to miss this birth for the world.  

Fortunately Luca slept soundly throughout Jonah’s birth.  I laboured from 10.30pm until his birth at 3.40am.  Mark, Jonah, Laura and I finally snuggled up in bed (King-sized!) at 5.15am – right at Luca’s wake-up time!  He came into bed with us and was far more interested in getting his morning feed and cuddle than he was in his new brother.  No surprises there!  Mum had bought Luca a couple of new toys and so he was happily enticed out to the lounge to hang out with his Nonny, leaving the rest of us to get some well deserved rest.

The following two days and night saw Jonah feeding almost constantly.  Clearly he was working hard to bring my milk in.  Luca wasn’t bothered in the least that there was another little person sharing his Mama’s boobs.  He was quite affectionate with Jonah, giving him little pats and waves – very cute!  Initially Luca didn’t seem to mind that his Mum’s time was being taken up by his new brother, probably because he had his Daddy at home to play with and oblige his frequent desire to venture outside.

The second morning following Jonah’s birth gave my boys and I our first taste of ‘true’ tandem feeding – one boy at each breast at the same time.  With Mark’s help to latch Jonah I managed to pull this off quite easily.  I was lying on my back with one arm under each baby to prop them up a little.  However, the angle that Luca was on meant his feeding felt somewhat uncomfortable for me – it felt as though his teeth were biting in a bit. The next time I fed them together I was sitting up on the couch and that was a lot easier and more comfortable.


 With two babies feeding from me I expected that my milk would come in faster than usual, though this did not end up being the case.  Day three saw my milk come in and Jonah was instantly more satisfied, thus spreading out his feeds to 1 – 3 hourly and getting good sleeps in between.  Luca didn’t seem phased by the sudden change in milk flow (I thought he’d be quite excited), nor did the change alter his time at the breast as I’d expected and hoped.  This reiterated the point for me that Luca’s time at the breast is much more about comfort and closeness than it is about food.

On that note, Luca’s appetite has decreased dramatically of late, and he is getting notably chubbier, plus wetting and soiling a whole lot more nappies!  That breast milk he is getting sure is working its magic.  I’m not sure if I should be cutting back his breast feeds and trying to get more solid food into him or whether to just go with the flow.  

With my first two babies I had an overly abundant milk supply.  This caused me some grief with regards to an extremely strong let-down reflex which caused my babies to choke and get upset, and the annoyance of very leaky boobs.  One of the big bonuses of tandem feeding has been that my milk supply is a lot more manageable.  I don’t get a strong let-down reflex so Jonah doesn’t have to battle the flow, and I’m not having anywhere near the leaking that I had with the other two.  Yay!  Furthermore, Jonah has been an excellent feeder from the start so I haven’t had any nipple trauma like I did with Laura and Luca.  Breastfeeding has, thus far, been a breeze and little Jonah is rapidly gaining weight.

Although Luca coped well with the new family dynamics during the first week of Jonah’s life, the second week has seen him become a lot more clingy with me, and much more grizzly in general.  When I am feeding or cuddling Jonah, Luca frequently gestures for me to put Jonah into his crib.  Mark and I do our best to give Luca a lot of our time and energy when we can, but I think the reality that this baby is staying for good has probably hit home for him.  I’m sure he’ll thank us one day for providing him with a playmate but for now it’s quite a difficult adjustment.  Thankfully Luca still has the comfort and security that breastfeeding provides to help ease him through this transition.  I am so grateful that I am able to at least offer him that.

Diary of a Tandem Feeder - Part 3

In the previous two 'Diary of a Tandem Feeder' blog posts I wrote about my experiences of breastfeeding during the first 24 weeks of pregnancy (to view the first post click here). This post covers weeks 25 to 34.

‘Thank goodness Luca is still breastfeeding!’ is what first comes to mind when I revisit the past couple of months in my mind.  Over the last three weeks Luca has been a miserable lad with teething (his eye teeth and bottom canines are all surfacing at the same time!) and illness.  He has suddenly gone from being a very placid, cruisy, happy little guy, to being a real grump who doesn’t like to be put down and who grizzles or cries whenever we are failing to read his mind and jump to his every demand.  It’s been gruelling, and often the only respite from his incessant moans has been when he’s breastfeeding (which, thankfully, he has been doing a lot of while he has been sick and miserable).  

Not only has his breastfeeding been a welcome relief from his moaning, it has also been a very helpful source of comfort on a number of other fronts.  First and foremost, breastfeeding has sometimes felt like the only thing I have been able to do for him that I know he finds comfort, security and pleasure in, so when his favourite toys, books or foods didn’t help him overcome his discomfort and unhappiness, the breast still did.  Also, for a couple of weeks he barely ate anything, probably because of the pain associated with eating while teething.  The fact that he was still breastfeeding reassured me that at least he was still getting the nutrients he needed through breast milk.  And finally, it was just something pleasurable we could share in when we were both experiencing a pretty exhausting and difficult phase in our lives, which counts for a lot!

Since about 25 weeks of pregnancy I feel that my milk supply has been increasing.  This might sound like an obvious physical response to Luca’s increased frequency and length of breastfeeds – most of us understand how the hormonal response to an increase in demand results in an increase in supply.  However, when pregnant, the hormones of pregnancy override the breastfeeding hormones so that increases and decreases in milk supply are a result of pregnancy hormones as opposed to what the toddler is doing at the breast.  Luca has stopped switching quite so much from breast to breast during a feed, and my breasts are growing in readiness for our next baby.  No complaints from Luca!

When I wrote one of these articles, Luca’s sleep was still appalling, waking most hours of most nights as he had done since four months of age.  I am extremely relieved to be able to say that he is now a good sleeper!  Even through his teething and time of illness, I was only up to him once or twice in the night.  Incredible!  It would be another whole article for me to write how he went from being an atrocious sleeper to being a good sleeper so it is not something I intend to write about just now, but I will say that I feel so grateful that we have overcome that massive hurdle before the baby arrives – fingers crossed it lasts and that I’m not eating my words in the next article!  It’s a little unfortunate that I am at that stage in pregnancy where I am not getting much sleep due to bladder squashing, indigestion and difficulty in getting comfortable.  Oh well, it would probably just feel like a big tease if I were finally to start getting a decent nights sleep just a few weeks before a newborn arrived with their inherent lack of sleep.

Breastfeeding Luca with my ever expanding belly is becoming more challenging – still very ‘doable’ but just quite awkward.  I have tried different positions to feed him but rarely feel the need to use them.  One such position is sitting on the couch with him cuddled into my arm next to me, his legs across my lap.  Another is feeding him lying down, both on our sides facing each other.  Interestingly, my belly is much smaller this pregnancy than it was with my other two.  Perhaps it’s just nature’s way of ensuring a reasonably comfortable breastfeeding relationship between Luca and I can continue throughout – I really couldn’t imagine how I would have managed to comfortably feed a toddler in the latter stages of my pregnancy with Luca.

When at a La Leche League (LLL) meeting recently, I asked one of the leaders (someone who has tandem fed her children) if she had any advice with regards to preparing Luca for the arrival of a new baby.  I told her that I was aware that I had been denying him feeds when I felt he was requesting them ‘unnecessarily’ (by that I mean times when he asked to be fed when he wasn’t hungry, hurt or upset).  I would use distraction techniques or offer him something yummy to eat instead because I felt worried that I would not be able to feed him so frequently and at his leisure when the baby arrives.  The LLL leader said that a toddler’s breastfeeding response to its mother’s pregnancy and to a new sibling is completely unpredictable.  I may still lose my milk, even at this late stage in pregnancy and Luca may then self wean; he might choose to wean when the milk changes to the thick, fatty colostrum I will produce for the baby; he might be jealous of the new baby at my breast and want to feed every time the baby feeds; he might not be too phased by the new baby and just continue to feed as he does now.  Who knows?  For that reason, she felt that there wasn’t really much she could suggest in the way of preparing Luca.  I took her advice (or lack thereof) and decided not to put any restraints on Luca’s requests for feed and, boy, it feels so much better.  I love feeding him and want to revel in the joys of our mummy-Luca breastfeeding relationship while I can.  Who knows what’s around the corner?

Choosing a Midwife - A Guide For the Non-Birth Nerds Out There

If you're a birth nerd like me, you won't need advice around choosing a good midwife. You'll have read enough birth stories and birth articles to appreciate how influential the midwife can be in the whole pregnancy, birthing and new parenting thing, and you'll have a fair idea about what it is you're seeking in a midwife. This blog post is designed to assist the novices out there, and also those of you who didn't get what you wanted out of a previous midwife you had.

Writing a guide to help you find the right midwife for you requires some assumptions on my part about what you want from your pregnancy and birthing experience (something you may not have even considered at this stage). Read the following points and if they feel right for you, this blog may be particularly helpful in guiding your choice of midwife...

• you view pregnancy and birth as normal, healthy experiences, not illnesses 
• you want to be an active participant in decisions around your pregnancy and birth care and appreciate the importance of being well-informed
• you are prepared to take responsibility for your health and wellbeing during your pregnancy, such as eating well, minimising alcohol intake, etc.

Whoever you end up choosing as your midwife, they need to be someone who you feel you will develop a good rapport with and whose philosophy and practice will support you to achieve an holistically positive and safe birth outcome (by 'holistically' I mean relating to the 'whole' of your being - not just physical aspects, but also mental, emotional and spiritual). Therefore, you will probably need to meet with and interview a number of midwives to determine who is the best fit for you. As a starting point, I suggest you get recommendations from friends who have had positive birth experiences, especially those who had minimal medical interventions. I know this will sound a bit biased of me but women who chose to birth at home and who felt well supported by their midwife to do just that, will probably be the best ones to get recommendations from. 

Even if you have no intention of birthing at home, midwives who predominantly care for home birthing women tend to have a stronger belief in the benefits of natural birth and their practice is more likely to reflect this. In other words, midwives who attend a lot of home births are, in my experience, less likely to interfere with a healthy birth process and are more likely to assist and support women to make fully informed decisions about their care. Of course I am generalising here and just as there are some excellent midwives who don't do many home births, there will also be home birth midwives who do not do their job well. So, how do you ascertain which midwife will be a good fit for you? You set up a time to meet and talk with them and you find out about important aspects of their practice. The following are some examples of the sorts of things that you may want to ask...

"Tell me about your philosophy around birth." This may seem a bit of a wishy-washy question to ask, but the answer will likely reveal a lot about the midwife's beliefs and practice. Does she talk about birth being natural and healthy? Does she talk about the partnership between herself and her clients, and of supporting women to make well informed decisions around their care? Does she acknowledge the importance of 'continuity of care' or 'following through' with a client's care right through her pregnancy, labour, birth and postnatally? The language she uses may be quite revealing... does she use the word 'client' or 'women' to refer to the women she cares for, or does she refer to her 'patients'? (pregnant women are not sick!) Does she talk about 'attending births' or 'delivering babies'? (remember here that it is the woman, not the midwife, who 'delivers' their baby). These are just a few examples of what might be revealed when you ask this question.

"Do you have any children of your own? What were your experiences of giving birth like?" Although a midwife doesn't need to have given birth/become a mother to be a good midwife, in my personal experience, it does help. Being a mother herself, the midwife can more fully appreciate the importance of the birth process and the midwife-woman relationship, and she has greater insight into the intensity of birth and new motherhood. Plus mothers tend to be stronger at voicing their opinions when it comes to important matters, which I believe is an important quality for midwives to possess (your midwife may need to advocate for you and it helps if she is strong and confident in this regard). Asking her about her own birth experiences will likely reveal more of her underlying beliefs around birth.

"What are your thoughts on home birth?" Regardless of whether you think you might want to birth at home or not, this is a good question to ask because you will be able to establish her true thoughts around 'natural birth'. Is she really positive about home birth, or does she have a lot of reservations? Has she had much experience with attending home births? If not, why not? It may be because few women in her area are seeking them out, but quite possibly it's because she isn't forthcoming with the information that home is an appropriate and positive birth option for most women during her antenatal care of them. This would ring alarm bells for me - if she does not trust the normal birth process then surely she is more likely to intervene with labours unnecessarily. Not good!

"How long have you been a midwife?" If she is a bit inexperienced, ask who mentors her and what involvement her mentor has in her practice. Or if she is no longer mentored, does she work with a supportive midwife partner/team of midwives who share a similar philosophy and practice to hers?

"What antenatal care will you provide?" Most midwives see their clients once a month from 12 - 28 weeks of pregnancy (sometimes starting earlier in the pregnancy), then fortnightly until 36 weeks, then weekly until birth. Some midwives expect you to come to their clinic whereas others are happy/prefer to come to your home (I liked the home visits because it kept birth feeling very 'normal' rather than feeling more like a doctors appointment). Some midwives will take 20 - 30 minutes to do an antenatal appointment (take your blood pressure, get you to pee on a stick, feel your tummy to see how baby's growing... and that's about it!). Others do those things PLUS sit and talk with you for up to an hour, sometimes more if needed. This talking is a VERY important aspect of your care. There are a lot of important matters that you will need to discuss with your midwife... about coping with pain in labour, about breastfeeding, about vitamin K, about your fears, about your hopes, etc etc etc.

"What labour care will you provide?" "What if I need to transfer to hospital?" (if planning a home birth) Your midwife should be willing to stay with you from when you feel you need her until a couple of hours after you have birthed your baby and placenta. If you have a particularly long labour your midwife may need to take a break and get someone else to take over for a while so that she can feel re-energised and safe to continue supporting you. This same care should apply regardless of where you plan to birth. If you are planning a home birth and end up needing to transfer to the hospital your midwife should continue to support you in the hospital setting, even if that is just in a 'support person'/advocacy type role (some home birth midwives don't have an 'access agreement' at the hospital so won't be permitted to carry out other parts of the midwife's role).

"If pregnancy becomes complicated or if I end up needing a c-section will you remain involved in my care?" Your midwife may refer you to a specialist for consultation if a complication arises. She should, however, continue to be your primary maternity care provider. It's my understanding that NZ midwives get paid a minimal birth fee if they choose to attend elective caesareans, and get paid the full birth fee for attending emergency caesareans. Therefore, it would be solely for the benefit of her clients if your LMC midwife chooses to attend elective c-sections. I know I certainly did when I practiced midwifery. If I had needed an elective caesarean section, I would certainly have liked for my midwife to be there to support me. 

"What postnatal care do you provide?" In my experience, this is a very 'telling' part of a midwife's philosophy and practice. NZ midwives are only required to do a minimum of 7 postnatal visits in the 4 - 6 week period following birth. Of course they can choose to do more but they will not be paid a higher postnatal fee for doing so. When I was a midwife I used to visit new mothers every day following birth until they felt comfortable to go a day or two without seeing me. I would then, in consultation with them and taking into account their personal needs, space the visits out more and more until the final visit at 6 weeks. By wholeheartedly supporting women during the postnatal period, midwives are much more able to provide the mother with the information and support needed to increase her confidence and help stave off potential issues like postnatal depression, breast infections, etc (or to give her additional assistance if those problems do arise). Some midwives (particularly those with large caseloads) only give the minimally required postnatal care to all women regardless of their individual needs. Ask what the average amount of care the midwife gives to first-time mothers is. It's a really important part of the care you receive but something you often don't really consider all that much until you need it (the birth is often the main focus for first-timers). Even if you live semi-rurally or remote-rurally, your midwife should still be coming to your home to carry out your full postnatal care (midwives can apply for a travel-costs fee if this is the case).

"What 'time off' do you have?" "What if you can't be at my birth?" "Who will be my back-up midwife?" "Will I get to meet her during my pregnancy?" You spend your pregnancy developing a trusting relationship with your midwife so it's reassuring to know that she is likely to be the one who will care for you when it comes to your labour and birth. Some midwives take more holidays/time-off than others (they have their own families to find time for and will need some time to themselves to prevent burn-out), but whatever their individual time-off schedule, make sure it is one that you feel comfortable with. If she is unavailable at the time of your birth then it is important that you have had the opportunity to get to know the back-up midwife prior to birth to make sure you feel comfortable with her. Most midwives work with another midwife(s) who shares a similar philosophy and practice to their own, but it will pay to ask whether this is the case for each midwife you interview. Note also that if a midwife is going to be on holiday shortly after you are 'due' then there is a high possibility that she will a) be unable to provide your postnatal care (so another midwife will give that part of your care), and b) that she will miss your birth (lots of babies choose to come well after their 'due date').

"How many women do you book each month?" Another really important question! The more women a midwife cares for, the less time she has for each of her individual clients, and the higher the likelihood that she will be attending someone else's birth when you give birth. The midwives who have high caseloads are, from what women have told me, useless at providing care that extends beyond the mere basics. They are the ones who do 20 minute antenatal appointments in their clinics; they are the ones who rush women's labours eg. prefer to unnecessarily (and inappropriately!) rupture her membranes; and they are the ones who provide the minimal postnatal care that is required of them. The NZ College of Midwives recommends that midwives book no more than 4 - 6 women per month (though I, personally, would be dubious of a midwife who attends an average of 6 births per month).

"Can you tell me some of your basic practice statistics?" Such as...

What % of the births you attend take place a) in hospital, b) in a birth centre, and c) at home? I would feel more trusting of a midwife's practice and philosophy if she was very experienced with attending births outside of the hospital. Midwives who support and encourage home and birth centre births are more likely to believe that birth is a normal, healthy process that, for most women, is most suited to taking place outside of the hospital environment (hospitals are for sick people and those in need of medical intervention). Hospital birth should be the exception rather than the rule for healthy women.

Of the planned home births, what % of your clients end up transferring to hospital? The number here should be very low if the midwife trusts the normal birth process, if she is patient and if she is knowledgeable about the normal variations associated with birth (ie. transfer is only necessary if complications occur that necessitate obstetric intervention, not simply because a woman is taking a long time to give birth, for instance).

What % of your clients have a caesarean? The World Health Organisation recommends that the caesarean section rate should be lower than 15% (around 1 in 4 women give birth via caesarean in NZ, and the rate keeps climbing). I would be looking for a midwife whose caesarean rate was lower than 15% (preferably less than 10% on average) because I don't honestly believe that more than 10% of women are incapable of birthing their babies without the need for a caesarean.

What % of your clients have an Induction of Labour? One of the reasons the c section rate is so high is because nationally we have such a high rate of induction (one medical intervention often leads to another, such as the drugs used to stimulate labour causing distress in the baby). I can't find the stats but I am all too aware that we have a very high rate of medical induction for 'post dates' pregnancies. If your pregnancy happens to last longer than 42 weeks (which something I recently read said that up to 10% of pregnancies do), you may be advised to undergo an induction of labour and, most likely, will be scared by the medical establishment into doing so. But more and more research is countering the argument that going beyond 42 weeks of pregnancy is risky. Your midwife should be forthcoming in providing you with all the relevant research you need, and supporting you, to make an informed decision that is right for you. She should also prepare you for the sorts of things the obstetrician is likely to advise if you decide to have a specialist consultation. Knowledge is power! Make sure you exercise your right to informed decision making and consent. That said, I would be very wary of a midwife who has a significant induction of labour rate. A midwife I talked to today said that she sometimes goes for years without any of her clients having an induction, and that when they do it is extremely rare that it is for 'post dates'.

What % of your clients are exclusively breastfeeding at 6 weeks postpartum? The same midwife mentioned in the paragraph above said that 97% of her clients are exclusively breastfeeding their babies at the 6 week mark. "But," she said, "I put my all into supporting women to successfully breastfeed." It is important that you have a midwife who is 100% committed to supporting you to breastfeed your baby. The establishment of breastfeeding can be an incredibly challenging experience for some women, and the midwife needs to do her bit to ensure the woman is given the best chance of success. I had an horrendous time for the first few weeks trying to breastfeed my first child. We lived rurally and my devoted midwife would travel in every day (sometimes more than once!) to help me with my breastfeeding. I am so grateful for the support I received and went on to breastfeed my daughter for 3 years!

What phone support do you offer during my pregnancy, birth and postnatally? Your midwife (or her back-up) should be available for phone support 24 hours a day, 7 days a week throughout the entirety of your care. If you have any concerns at any time you should feel totally comfortable to call your midwife so that you can access information or treatment and/or allay your fears.

And, of course, ask any other questions that are important for you. For example, if you are particularly keen on alternative therapies you could ask whether she incorporates any alternative therapies into her practice (some midwives regularly use homeopathy and/or herbs, for instance). 

You will probably get a reasonable feel for who seems the right fit for you after interviewing a few midwives. If, during the course of your midwifery care, you become unhappy with your choice of midwife you are entitled to change your LMC at any time. Don't stick with a midwife because you feel obligated to... birth is too much of an important and precious occasion in your life to settle for a midwife who is not right for you. Also, be wary of settling for a midwife because she seems 'nice'. Sure, you want a midwife who you get on well with, but don't put nice-ness over and above other more important qualities such as knowledgeable, caring, wise, capable etc, etc. Nice midwives are sometimes not the best advocates because they fear stepping on someone else's toes (I know I was one of those 'nice' midwives - I was wonderful at looking after the emotional needs of my clients but sometimes I was a bit pathetic at voicing my opinion when it really mattered).

Finally, here are a couple of links that may be useful for you to read before you search out a midwife. This one is the NZ College of Midwives list of things you can expect from your LMC, and this one is a list of your rights during pregnancy and birth.

“Some midwives pull women up the hill and say I will get you through this. Other midwives walk behind quietly and gently say, ‘I believe in you.’” -Patricia M. Couch

This is seconds after I'd birthed my first baby into my mothers hands and she'd passed her to me between my legs. See my wonderful midwife quietly watching on from the side.

Diary of a Tandem Feeder - Part 2

In my last ‘Diary of a Tandem Feeder’ blog I wrote about my experiences of breastfeeding whilst pregnant during the first 17 weeks of my pregnancy. This blog is a continuation of the previous one and covers weeks 17 to 25.

Night weaning Luca was, much to my surprise, quite a breeze. He grizzled a bit but there were no major tears. What a relief! Unfortunately, I can’t say that night weaning him has improved his sleep at all. At 13 months of age he is still waking most hours of most nights (except for a longer stretch of sleep at the beginning of the night which is when I am awake anyway!). Still, it feels reassuring that he won’t be expecting to be fed in the night when there is another baby needing lots of night feedings. I am starting to feel somewhat anxious that Luca’s sleep isn’t going to have improved significantly before the baby arrives. The next logical step will likely be to get Mark (Luca’s Dad) involved in night time re-settlings. Watch this space!

At about 16 weeks of pregnancy I started experiencing quite a nasty, sharp stabbing pain whenever Luca initially latched at the breast. Having heard from a number of mothers who either tandem fed their babies or had the intention to, that painful breastfeeding during pregnancy (usually beginning around mid-pregnancy and associated with a decrease in milk supply) was the most difficult hurdle for them (an insurmountable one for some), I was quite worried that there was worse to come. Much to my surprise the painful latching abated after just a week or two. Yeehaa! I am now 25 weeks pregnant and breastfeeding Luca is pretty much pain free (apart from him occasionally using his teeth to grab and latch – ouch!). 

I am sure my milk supply has decreased rather significantly. Not only do I no longer experience let-downs or need to use breast pads, Luca has also started to switch from breast to breast during each feeding session. At the start of my pregnancy Luca would guzzle from one side for about 5 minutes and that was that, feed over, tummy full. Since about 19 weeks of pregnancy he has been feeding for about 20 to 25 minutes a feed, and often switches breasts 4 or 5 times during that time. I am pretty sure that he is only swallowing for the first couple of minutes and, thereafter, he just likes the comforts and pleasures of being close to mum while he sucks. In fact, sometimes he looks quite deliriously happy whilst feeding – as he relaxes, his eyes roll back and half close as if he is in ecstasy. At times like those I feel so besotted with my little guy and very grateful that I am still breastfeeding him.

My unborn baby whom I’ll refer to as a ‘she’ (I’m sure it’s a girl!) has certainly been making her presence known. She has grown a lot and is really active in there. Being so distracted with parenting Luca, I have found it hard to believe that I’m really pregnant at times, so it feels lovely and reassuring to have a bigger belly and feel my baby moving a lot. When Luca breastfeeds or lays in my lap when I am trying to get him back off to sleep several times in the night, his unborn sibling kicks furiously. It’s as though she is trying to kick him right off my lap!  I hope this isn’t because she is feeling uncomfortably squashed at these times. I guess it isn’t going to be long until Luca and I will need to start getting creative with breastfeeding positions. And in terms of the night time re-settlings in my lap, I am going to have to start getting tough with Luca and teach him to resettle in the cot.

Luca seems to be becoming more clingy towards me lately and less tolerant of Mark or Laura cuddling me. This is making me feel a little anxious about how he will cope with sharing me with a newborn, especially with regards to breastfeeding. Is he going to expect to be fed every time he sees his sibling feeding? Is he going to be physically pushy with her and not allow her the peaceful breastfeeds she’s entitled to? No doubt it is going to be a steep learning curve for him (and me!) and will require some adjusting, I just hope that that won’t involve too much stress for any of us. My sisters have both suggested I get Luca into a breastfeeding routine, thinking that might be helpful for when the baby arrives. They figure that if he has set feeding times that he will hopefully be less insistent on feeding whenever he sees the baby feeding. It probably makes sense, but I am just not a routine-type person and can’t foresee myself (or Luca) sticking to a schedule. Furthermore, most of his feeds are requested by him when he seemingly has an emotional need to feed, such as when he hurts himself, or when he hasn’t seen me for a couple of hours. Breastfeeding Luca at this stage in his life is much more about an emotional need than a physical one. 

I am pleased to be able to say that I haven’t experienced any negativity towards my intention to tandem feed since I last wrote.  A lot of people have seemed genuinely interested in my keenness to continue feeding Luca when the next baby arrives and I have enjoyed the opportunities this has given me to educate them about the possible benefits of tandem feeding.  

Diary of a Tandem Feeder - Part One

Back in 2009 I became pregnant with my third child. My daughter, Laura, was seven at that time and my son, Luca, was eight months old. I was still breastfeeding Luca when I became pregnant and hoped that I could continue to breastfeed him for a long time to come (I'd breastfed Laura until she was three).  I began journalling my experiences of breastfeeding whilst pregnant which, later, transitioned to a diary of my tandem feeding journey. 

Originally these diary entries were published in the Waikato Home Birth Association's magazine, called 'B', and later they were published in Home Birth Aotearoa's magazine, 'Birthplace'. I had a lot of positive feedback from readers about these articles, so thought I'd start posting one per week on my blog in case others might enjoy them, and benefit from reading them, too.  

Breastfeeding Luca at 4 months

Pregnant and Breastfeeding

Gee, I never realised there were so many people out there ignorant of the concept ‘tandem breastfeeding’.  I guess tandem breastfeeding has been such a common occurrence amongst the mothers I associate with that I had not realised what a little-known and poorly understood parenting choice it is amongst the general public.  For those of you reading this who have not, yourselves, heard of tandem breastfeeding before, it is where a mother continues to breastfeed her toddler whilst breastfeeding her newborn (actually, it means breastfeeding more than one child, so it applies to breastfeeding twins or triplets too).

When my son, Luca, was eight months old I became pregnant again.  I am now 17 weeks into my pregnancy.  Although really excited to have become pregnant with my third child, I did feel anxious that it may mean Luca would wean much earlier than I would be comfortable with.  Most pregnant women who are still breastfeeding have a large drop in their milk supply at about mid-pregnancy, and sometimes this leads to the toddler choosing to wean (or the mother choosing to wean her toddler because ‘dry’ feeding can be very painful).  Also, the pregnancy hormones alter the taste of the milk and this too, can cause a toddler to wean even from very early on in the pregnancy.

I have decided to keep a diary of my experiences as a pregnant breastfeeding mother, and hopefully, one day, a tandem breastfeeding mother. 

First 12 weeks of pregnancy

If my milk has changed flavour Luca certainly doesn’t seem to mind the taste.  He is still the eager feeder he has always been.  In fact, I haven’t noticed any changes in our breastfeeding relationship at all so far, the pregnancy hasn’t even caused me any breast or nipple tenderness.  This certainly feels like a positive start.  Furthermore, I haven’t been suffering much morning sickness at all.  Nothing like when I was pregnant during my first trimester with both Laura and Luca.  I’ve started reading the book ‘Adventures in Tandem Nursing’ by Hilary Flower which does say that for some women pregnancy lessens morning sickness and for others it makes it worse.  Guess I’ve got lucky!  

One big change has been my appetite.  When breastfeeding, I eat loads.  When pregnant, I eat loads.  When pregnant and breastfeeding, I eat mountains!  My stomach is a bottomless pit.  I even put Mark (my big hubby) to shame at the dinner table (I think he’s quite shocked at how much food I can put away!).  And if I don’t snack frequently throughout the day my blood sugar seems to drop super fast which is the only time I ever really feel queasy.

It’s strange, but because I’m not experiencing hardly any morning sickness and because I haven’t experienced any breast tenderness, I’m finding it hard to believe I am really pregnant.  In saying that, I can no longer fit most of the clothes that I have only recently started fitting again since birthing Luca, but that might just be because I am eating like a hippopotamus.  Depressing!  When my midwife came to visit at 12 weeks I even asked her to have a listen for the baby’s heart beat with the Doppler (which I typically wouldn’t bother with).  I just felt I wanted some convincing that there really was another baby on the way.  And, of course, there was the reassuring little ba-dum-ba-dum-ba-dum-ba-dum of my baby’s heart.  Okay, so it really is happening.

12 – 15 weeks

A number of my friends have seemed quite shocked that I am still breastfeeding Luca even though I am pregnant.  They hadn’t thought it possible to get pregnant whilst breastfeeding.  Interestingly, when I was breastfeeding Laura, I didn’t start getting my period again until she was 19 months old, but with Luca, he was just 5 months old.  This was probably because Luca had a couple of long stretches of sleep (6 or 7 hours) at night when he was a newborn. Unfortunately, gone are those days – Luca hasn’t tended to sleep more than 2 hours (3 hours max) at a stretch for months.  I think Laura was about 4 years old before she had her first 6 hour stretch of sleep!

My massive hunger hasn’t abated in the slightest.  I now do not leave the house without a source of food.  The ‘pick and mix’ section at the supermarket has become my feasting saviour.  I always have a ready supply of dried fruits and nuts.  It feels very reassuring having some of these stored in my car glove box and hand bag!  Certainly beats the nausea and faintness I quickly feel if I let my blood sugar drop.

Luca is still a terrible sleeper and I am starting to feel anxious that this may not resolve itself before the next baby comes.  Since he was four months old he has woken hourly through most of the night, most nights.  We decided to employ a wonderful baby sleep ‘specialist’ to help us sort out his sleep (one who does not advocate leaving a baby to cry on it’s own as a means of learning to sleep).  So far progress has been slow, but I do feel confident that we will get there.  At the very least, Luca has learnt that he does not need a breastfeed to get back off to sleep every time he wakes at night.  He is now down to just two night feeds.  I intend to completely night wean him before the next baby arrives (couldn’t imagine trying to breastfeed two babies through the night), so this is a good start.

Mark’s nana has given me my first wee taste of negativity towards my intention to tandem feed.  She’s a lovely woman and was certainly very sensitive and sweet in how she broached the ‘issue’ with me.  Her concern is that my health will suffer too much if I am feeding two littlies, especially because my babies never seem to allow me much sleep.  I felt quite defensive, but I suppose she may have raised an important point – just how will my body cope?  I am already feeling rather exhausted.

Another ‘downer’ has been the discussions I have been having with women who have tandem fed or were keen to but unable.  The stories have tended to be more negative than positive which I have found quite disheartening.  It seems that for most of the women I have spoken to, the physical pain of breastfeeding during pregnancy has been a massive (sometimes insurmountable) hurdle for them.  I haven’t experienced any such pain yet, but they tell me that it starts about mid pregnancy for most.  Time will tell I guess.

15 – 17 weeks

Beginneth the pain of breastfeeding whilst pregnant!  Over the past couple of weeks it has become increasingly painful when I initially latch Luca at the breast.  Thankfully the pain is only brief and, at this stage, quite bearable.  It feels like it did when Luca was a newborn and my nipples were recovering from a bit of surface grazing.  My milk supply must have decreased a bit as I no longer need to wear breast pads for leaking – perhaps this is why the tender latching has started.  

Luca started to request very frequent feeding a week ago.  I thought he was just going through a particularly clingy phase but it turns out he was keen to kick into the solids in a big way (perhaps due to the decreased milk supply).  He has never been into solids much at all until this point and it is quite an adjustment for me having to prepare and feed him lots of food. Breastfeeding is so much more convenient and easy!

Nights are still rather rough.  The plan is soon to night wean Luca completely in the hope that this will lead to longer stretches of sleep.  I have to psych myself up for it though because I know it is going to involve less sleep and more tears (for both Luca and myself!) before it helps.  Wish us luck!

I have been attending monthly Le Leche League meetings and they are fantastic – such an awesome source of information and support.  I figure such help may well become essential if breastfeeding during my pregnancy becomes a big challenge.

Early in my pregnancy. Luca (10 mths), me, Laura (7yrs) and Mark

Scanning For Trouble

I was working as a midwife when I found out I was pregnant with my first child. I had no idea how far along my pregnancy was and allowed myself the excuse that, as a midwife, I needed to know when I was due so that I didn't book anyone whose due date was too close to mine. So, off I went to my 'dating scan', excited at the prospect of seeing my little baby on a screen.

The scanning process turned out to be a rather invasive one. Being so early on in my pregnancy the ultrasonographer told me I'd need a trans-vaginal scan - immediately my romantic notions of 'seeing' my unborn child were diminished (this, by the way, was the only 'internal examination' of any sort that I had throughout all three of my pregnancies and births). But the worse was yet to come... My tiny unborn child had no heartbeat. "The size of your baby suggests an age of 5 1/2 weeks, by which time we would usually be seeing a beating heart," the ultrasonographer plainly informed me. "Come back for another scan in 7 -10 days and we'll check for a heartbeat again."

The week that followed was torture. I didn't know whether a was carrying a live or a dead child in my womb. Each day, until that next scan, felt like an eternity. Thankfully, the following scan showed a vigorously beating heart within my child's chest. I resolved, there and then, not to have another pregnancy scan unless there was a damn good reason to do so.

Over the 17 years that have passed since the beginning of my midwifery training I have come across many women whose pregnancy ultrasound scans have caused a lot of needless stress. The WHO does not recommend the use of routine ultrasound scans during pregnancy. This is because outcomes for the baby do not improve as a result of such scanning. Yet many pregnant women view their routine 20 week scan as a 'rite of passage' and an accurate means of determining whether or not their unborn baby is healthy. Frequently they are not told of the limitations and possible adverse outcomes of routine scanning (click here for a comprehensive article on the concerns related to ultrasound scanning).

In discussing the 'to scan or not to scan' debate with others, I have often heard it argued that having a routine 20 week scan is chosen as a means of decreasing stress levels during pregnancy because these women believe they will be reassured that 'everything is okay' with their baby. Interestingly, this has even been said to me by women who have 'had to' have multiple scans because there was a concern about some thing or another... they couldn't see the heart properly; there was too little fluid around the baby; they were worried about the position of the placenta; the baby was too small; the baby was too big... things that ultimately did not turn out to be of any concern, yet for a period of time they caused some degree of anxiety for the mothers.

I, for one, choose not to have routine pregnancy scans in large part because I am scared of the anxiety that having a scan might create for me. In the absence of worrying signals in pregnancy, I prefer to assume that I am growing a healthy baby in my healthy body. Admittedly I have had the misfortune of coming across a disproportionately large number of women who had 'false positive' and 'false negative' scan 'findings' (the numbers of false positive and false negative findings are, according to all the research I have come across, very small) which has also helped to secure my conviction that routine scanning does more harm than good. Some of the more extreme examples have included:

• a routine scan (and many subsequent follow-up scans) 'showing' fluid on the baby's brain that the doctors warned the mother would cause her baby to be brain damaged and very unlikely to live for long (this baby was found to be completely healthy at birth)
• a routine scan 'showing' a major heart abnormality (this baby's heart was completely normal at birth)
• a routine scan failed to detect a diaphragmatic hernia which had resulted in the baby's organs growing into his chest cavity leaving little space for his lungs to develop (this baby died shortly after birth)

And I have also seen the devastating results of discovering difficult truths during a routine mid-pregnancy scan...

A friend of mine was joyously pregnant with her first child. At 20 weeks she and her husband went along for their scan, excited about seeing their baby on a screen and anxious to hear that 'all was well' with their baby. Sadly, the scan detected a major heart abnormality, one that would be incompatible with life outside the womb. My friend was given the choice to either be given an injection of something that would quickly end her baby's life, then being delivered of her dead baby; or to carry on her pregnancy until it's end and give birth to her baby, knowing that her baby would die shortly after birth. She was devastated. She couldn't bear to carry on her pregnancy and chose the first option.

Another friend was given the same tragic news at her routine 20 week scan... your baby's heart has an abnormality which is inoperable and will result in your baby dying shortly after birth. She chose to continue her pregnancy, suffering through the comments of well-meaning people who didn't know her reality: how's your pregnancy going?; when's your baby due?; have you got the nursery ready?; are you looking forward to the birth?; would you like some hand-me-downs for your baby?, and desperately trying not to feel too attached to her unborn baby. Her baby died in her arms within a couple of hours of being born.

I can't help but feel that if it was me, I'd rather have discovered this sort of tragedy after the birth. At least, that way, a positive pregnancy and birth could be experienced beforehand, which is far more preferable, to my way of thinking, than being faced with either of the situations that my friends had to live through. Of course there is never a good time to find out such devastating news. But finding out via a mid-pregnancy routine scan is not going to change the outcome, not in any sort of a positive way anyway.

A routine ultrasound scan in pregnancy is an unnecessary intervention, often the first 'trigger point' for a number of consequential interventions... interventions that research has shown do not improve the pregnancy outcome! Like other unnecessary medical interventions in pregnancy and birth, routine scanning can erode a woman's belief in her body's ability to naturally grow and birth a healthy baby - something which we all know should be the reality for the vast majority of birthing women. Choosing to have a routine scan in pregnancy needs to be an informed and considered decision, not a flippant choice... Just because you can, doesn't mean you should.