One of the many questions we ask at our hospital during the first prenatal visit is whether the mother intends to breastfeed her infant. The answer is usually some variation of “probably.” We strongly encourage moms to breastfeed, starting at that first prenatal visit and continuing throughout the pregnancy.
Regular encouragement by her health care provider(s) does seem to positively influence a woman’s decision to try breastfeeding her baby. But the encouragement of her own mother, her aunties and grandmothers is a stronger influence in whether she continues breastfeeding past the first few weeks. Extended family is a closely knit unit in the villages, often with multiple generations living under one roof. A new mom has many advisors.
Breastfeeding is strongly supported in Yupik Eskimo culture; many moms will breastfeed a child for two to five years, and some are nursing multiple children at one time. A woman came to clinic recently who was nursing a 4 year old, a 2 year old and a newborn. Many women are nursing an older child throughout their pregnancy, and only wean the older child when they have to come to Bethel for the last month of pregnancy. Cultural tradition is for a newborn to have exclusive right to breastfeeding; the belief is that the baby will not bond appropriately with the mother if the breast must be shared with older siblings. Some women lactate continuously for ten years or more, due to frequency of childbearing and extended patterns of breastfeeding.
Breastfeeding tends to inhibit ovulation, but many women do become pregnant while they are nursing. I have seen at least one patient who was nursing and already pregnant at her eight week postpartum visit. One reason for this may be the tendency of many moms to supplement breast milk with formula. The Women/Infants/Children (WIC) program supplies formula at no charge to the mother for her child’s first year of life, and most (if not all) women in our region qualify for the program. This easy availability of formula provides women a quick alternative if they have any problems with nursing. WIC does encourage nursing, and provides a free hand-operated breast pump to any mother who wants one. The WIC office here also has a grant-funded loaner program to supply electric pumps for short-term use. These machines retail for over $500, and work quickly, as they pump both breasts at once.
Southwest Alaska has one of the highest rates of initiation of breastfeeding in the entire U.S. It is rare to see a biological mom who is exclusively bottlefeeding, especially if she is more than 20 years old. Teen moms sometimes make little or no effort to breastfeed, but older moms almost always do. We have a fairly large rate of drop-off in breastfeeding when the baby is between six weeks and six months of age, but our breastfeeding rate at six months of age is still higher than most of the country. A small percentage nurse until four or five years of age. The oldest child I have seen still nursing was seven years old.
Instructions in breastfeeding are given to women who want or need them while they are admitted at the hospital for the delivery. We have one lactation consultant available; she is a family practice physician and nursing mom herself who had a strong personal interest in it and pursued certification. There is no La Leche League in Bethel or the YK Delta. Once a woman returns to her village, she has her own female relatives and the village health aides to help her. She rarely needs more.
Maternal complications from breastfeeding are most commonly cracked nipples, for which we give lanolin; and mastitis. The latter is a far more serious problem. Mastitis often develops quickly in Eskimo women and becomes severe. Deep abscesses are not uncommon, and occasionally the woman becomes febrile, bacteremic, even septic. We have very high rates of the dreaded MRSA, which is cultured from most of the abscesses we see. Cephalexin (Keflex) is essentially useless, our resistance rates to it are so high. Our most commonly used drug for abscesses is trimethoprim-sulfamethoxasole (Septra, Bactrim), but it is contraindicated in pregnancy and lactation, as is levofloxacin (Levaquin). We use ciprofloxacin (Cipro) much of the time. The deep and wide incisions needed for some of these breast abscesses can leave a woman with a very scarred breast.
Breastfeeding has been shown to reduce the rates of RSV, otitis media, and diabetes in babies who are breast fed. This is our strongest selling point to pregnant women. Our region has one of the highest rates--and greatest severity--of bronchiolitis in the world. Almost every home has a nebulizer, and almost every mom knows how to give a nebulized albuterol treatment and do effective percussion and postural drainage (P&PD)*. Yupik children have horrendous rates of acute and chronic otitis media. Draining ears are a daily staple in village clinics and in the hospital.
Overall, breastfeeding is easily accepted and widely supported in the Yupik Eskimo culture. On any given day, if you walk through the hospital waiting room, you may see a half dozen women nursing infants as they chat with family and friends around them. There is no hiding the baby under a blanket to do it, either. They are right there in the open, proud of their child, and their motherhood. It is the most natural thing in the world, and one of the most beautiful.
*Wikipedia had no entry to explain this. Many of our patients call it "pounding". The mom sits in a chair with one foot slightly elevated so that one knee is higher than the other. The child is placed face down on the lap with the butt on the higher knee and the chest on the lower knee (i.e., headed downhill). With her cupped hand, mom percusses ("pounds") the baby's back for several minutes. The vibration of this action helps shake loose the mucous plugs obstructing the baby's smaller airways and facilitates productive coughing to remove the mucus. P & PD following a nebulizer treatment enhances the effectiveness.
Labels: Bush Medicine