We encourage breastfeeding in our patients, but shouldn’t we be able to do the same for ourselves? August is Breastfeeding Awareness Month so let’s become aware of a few facts:
Fact #1: Breastfeeding is recommended by the American Academy of Pediatrics until at least age 1.
Fact #2: Meeting these breastfeeding goals is more common when adequate workplace resources are in place (a 2019 study from Alberta showed that half of residents discontinued breastfeeding due to a lack of resources and conflict with clinical duties).
Fact #3: Adequate workplace lactation resources do not exist for many women, and certainly do not exist for medical trainees returning from maternity leave.
Breastfeeding has medical and neurodevelopmental benefits for babies. Breastfeeding also correlates with improved cardiovascular and malignancy risk profiles in the mothers. Some women choose not to breastfeed and/or may not be able to breastfeed, and that is fine, too, but the reason for this happening should not be an inadequate workplace environment.
Workplace barriers that arise may be either interpersonal or systemic. In my own experience, interpersonal barriers have been fairly benign in that my colleagues have been well-intentioned and want to be supportive, but don’t necessarily have the knowledge to do so.
Systemic barriers, on the other hand, are inexcusable. Hospital and education leadership can and should provide the basic necessities to allow a breastfeeding trainee the ability to provide evidence-based nutrition to her child.
For most women, pumping will take at least the number of feeds the baby is taking, or anywhere from two to five sessions per day. Pumping is generally less efficient than direct breastfeeding, so some women will do a combination of pumping and direct feeding, while some will exclusively pump. Either way, supply is key.
Supply increases with demand – which is why, for example, a single woman can feed twins. Skipped, abbreviated or low-quality pumping sessions harm supply. To put this in a resident-life context, if a woman is on a rotation that is consistently busy and her usual three pumps per day becomes two pumps per day, her supply may drop.
Many of us acknowledge this as an inescapable reality and engage in planned “power pump” sessions on weekends off that involve long and/or frequent pumping to stimulate supply. These methods usually take three days to increase supply and the time commitment is not insignificant. Furthermore, incomplete emptying puts women at risk of mastitis. Finally, sudden drops in supply can occur with mild infectious illnesses and the return of menstrual cycles – facing this with an already tenuous supply can be daunting.
Imagine the following scenario. A resident steps away from work for her mid-morning pump. She walks to a distant wing of the hospital where she locks up her pump, walks to the obstetrics floor and asks to speak to the charge nurse, who appears after five minutes, spends three minutes looking for a clear hospital room, then advises using a storage room down the hall. The resident connects, and pumps for 20 minutes, interrupted by a custodian and a respiratory therapist. She packs up, walks back to the distant wing to put away her pump, returns to her unit, stores her milk and used pump parts in the nurses’ lounge fridge, and gets back to work. This took 50 minutes and no work-related activities were undertaken. This is a true story. With three sessions, pumping took up 2.5 hours of this resident’s day.
Now imagine the following. The resident steps away from work for her mid-morning pump. She walks to a nearby lactation room, where her pump is securely stored, sits down and connects to her pump at a workstation with a computer, where she checks her patient’s labs. She pumps for 20 minutes, uninterrupted, returns her pump to her locker, stores the used pump parts and milk in a fridge in the same room, and returns to work. This took 30 minutes but she also did useful work for at least half of that time. With three pumping sessions, only 45 total minutes were taken away from her duties.
A third scenario, which I hope is going to become more common, is the use of wearable pumps. These pumps are fully mobile, with motors either contained within the cup unit itself that sits in the bra or with short tubing connecting to a small external pump that clips onto a belt or fits in a pocket. The motor noise is generally audible but not intrusive.
Unfortunately, wearable pumps such as the Elvie, Willow or Freemie are not readily available for purchase in Canada, presumably due to longer maternity leaves here and therefore lower demand. This strategy still requires appropriate pump storage and fridge availability but enables full mobility. Surgeons use them, ICU physicians use them, and I can say from experience that they are stable enough for anything but performing CPR.
A lockbox, a fridge, and a workspace are the bare minimum to promote breastfeeding in medical trainees.
Breastfeeding is a serious learning curve for a new mum and the transition back to work can pose challenges. Currently, these challenges are being addressed by an outstanding Facebook group of breastfeeding physicians called Dr. MILK, who collectively seem to be able to solve any breastfeeding issue. I shudder to think that there may be resident physicians that have made the return to work without the knowledge of Dr. MILK. But shouldn’t a trainee feel support from their program as well?
I envision clean, well-equipped lactation rooms. I envision a lactation support person on PGME and UGME wellness committees, who could meet with a trainee during pregnancy to have preliminary discussions about parental leave, breastfeeding goals and a return-to-work plan, and then follow up post-partum to see if the trainee’s needs remain the same. I envision lactation champions spread across the country to help implement and maintain the recommended standards for trainee lactation support. I envision financial support for residents to buy decent pumps (a recent success in Ontario).
Even with the best of plans, there is an emotional toll to going home to sterilize pump parts every night. There is an emotional toll to having the occasional breast milk spill on your scrubs. There is an emotional toll to experiencing the drastic transition from pumping breastmilk one minute and running a Code Blue the next (or doing both simultaneously).
During Breastfeeding Awareness Month, if nothing else, let’s become truly aware of the courage and resolve that breastfeeding through medical training really entails.