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Breastfeeding and Racial Disparities in Infant Mortality: Celebrating Successes and Overcoming Barriers

As a part of Black Breastfeeding Week, Lactation Matters is reprinting (with permission) two editorials from Clinical Lactation, the official journal of the United States Lactation Consultant Association. Up today: a focus on the successes so far and places where IBCLCs can support change. Throughout the post, check out additional links that author Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA, has asked Lactation Matters to highlight as additional resources for our community.

Many exciting changes occurred in 2013 in the breastfeeding world. One of the best trends was the increase in breastfeeding rates in the African American community. The CDC indicated that increased breastfeeding rate in African American women narrowed the gap in infant mortality rates. As the CDC noted:

From 2000 to 2008, breastfeeding initiation increased . . . from 47.4% to 58.9% among blacks. Breastfeeding duration at 6 months increased from . . . 16.9% to 30.1% among blacks. Breastfeeding duration at 12 months increased from . . . 6.3% to 12.5% among blacks.

Much of this wonderful increase in breastfeeding rates among African Americans has come from efforts within that community. In 2013, we saw the first Black Breastfeeding Week become part of World Breastfeeding Week in the U.S. Programs, such as A More Excellent Way, Reaching Our Sisters Everywhere (ROSE), and Free to Breastfeed, offer peer-counselor programs for African American women.

Check out the Black Mothers’ Breastfeeding Summit

We can celebrate these successes. But there is still more to do. Although the rates of infant mortality have dropped, African Americans babies are still twice as likely to die. In addition, although rates of breastfeeding have increased among African Americans, they are still lower than they are other ethnic groups.

For each of the 2000–2008 birth years, breastfeeding initiation and duration prevalences were significantly lower among black infants compared with white and Hispanic infants. However, the gap between black and white breastfeeding initiation narrowed from 24.4 percentage points in 2000 to 16.3 percentage points in 2008.

Barriers to Overcome

In order to continue this wonderful upward trend in breastfeeding rates, we need to acknowledge possible barriers to breastfeeding among African American women. Here are a couple I’ve observed. They are not the only ones, surely. But they are ones I’ve consistently encountered. They will not be quick fixes, but they can be overcome if we recognize them and take appropriate action.

1) Pathways for IBCLCs of Color. In their book, Birth Ambassadors, Christine Morton and Elayne Clift highlight a problem in the doula world that also has relevance for the lactation world: most doulas (and IBCLCs) are white, middle-class women. And there is a very practical reason for this. This is the only demographic of women that can afford to become doulas (or IBCLCs). The low pay, or lack of job opportunities for IBCLCs who are not also nurses, means that there are limited opportunities for women without other sources of income to be in this profession. Also, as we limit tracks for peer-counselors to become IBCLCs, we also limit the opportunities for women of color to join our field. I recently met a young African American woman who told me that she would love to become an IBCLC, but couldn’t get the contact hours needed to sit for the exam. That’s a shame. (I did refer her to someone I knew could help.

2) We need to have some dialogue about how we can bring along the next generation of IBCLCs. We need to recognize the structural barriers that make it difficult for young women of color to enter our field. ILCA has started this dialogue and held its first Lactation Summit in July to begin addressing these issues.

These discussions can start with you. Sherry Payne, in her recent webinar, Welcoming African American Women into Your Practice, recommends that professionals who work in communities of color find their replacement from the communities they serve. Even if you only mentor one woman to become an IBCLC, you can have a tremendous impact in your community. If we all do the same, we can change the face of our field.

3) Bedsharing and Breastfeeding. This is an issue that I expect will become more heated over the next couple of years. But it is a reality. As we encourage more women to breastfeed, a higher percentage of women will bedshare. As recent studies have repeatedly found, bedsharing increases breastfeeding duration. This is particularly true for exclusive breastfeeding.

Bedsharing is a particular concern when we are talking about breastfeeding in the African American community. Of all ethnic groups studied, bedsharing is most common in African Americans. It is unrealistic to think that we are going to simultaneously increase breastfeeding rates while decreasing bedsharing rates in this community. The likely scenario is that breastfeeding would falter. It’s interesting that another recent CDC report, Public Health Approaches to Reducing U.S. Infant Mortality, talks quite a bit about safe-sleep messaging, with barely a mention of breastfeeding in decreasing infant mortality. A more constructive approach might be to talk about being safe while bedsharing. But as long as the message is simply “never bedshare,” there is likely to be little progress, and it could potentially become a barrier to breastfeeding.

Don’t miss the Interview with Sherry Payne on Fighting Breastfeeding Disparities with Support.

Reason to Hope

Even with these barriers, and others I haven’t listed, Baby-Friendly Hospitals are having a positive effect. When hospitals have Baby-Friendly policies in place, racial disparities in breastfeeding rates seem to disappear. For example, a study of 32 U.S. Baby-Friendly hospitals revealed breastfeeding initiation rates of 83.8% compared to the national average of 69.5%. In-hospital exclusive breastfeeding rates were 78.4% compared with a national rate of 46.3%. Rates were similar even for hospitals with high proportions of black or low-income patients (Merewood, Mehta, Chamberlain, Phillipp, & Bauchner, 2005). This is a very hopeful sign, especially as more hospitals in the U.S. go Baby-Friendly.

Click here to watch the Teach Me to Breastfeed Rap!

In summary, we have made significant strides in reducing the high rates of infant mortality, particularly among African Americans. I am encouraged by the large interest in this topic and the number of different groups working towards this goal. Keep up the good work. I think we are reaching critical mass.

And thanks for impacting your community—one mother at a time. Wishing you a happy and healthy 2014.

Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

Editor-in-Chief, Clinical Lactation


Merewood, A., Mehta, S. D., Chamberlain, L. B., Phillipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in U.S. Baby-Friendly hospitals: Results of a national survey. Pediatrics, 116(3), 628-634.

Reprinted with permission from Clinical Lactation, Vol. 5-1

About the Author

Dr. Kendall-Tackett is a health psychologist and International Board Certified Lactation Consultant, and the Owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett is Editor-in-Chief of Clinical Lactation, Fellow of the American Psychological Association in Health and Trauma Psychology, President of the APA Division of Trauma Psychology, and Editor-in-Chief-elect of Psychological Trauma. She is a Clinical Associate Professor of Pediatrics at the Texas Tech University School of Medicine in Amarillo, Texas and Research Associate at the Crimes against Children Research Center at the University of New Hampshire. Her most recent books include The Science of Mother-Infant Sleep (with Wendy Middlemiss) and Psychology of Trauma 101 (with Lesia Ruglass). Her websites are and


Childbirth-Related Psychological Trauma: An Issue Whose Time Has Come

By Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

I first became interested in childbirth-related psychological trauma in 1990. Twenty-three years ago, it was not on researchers’ radar. I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births. I was convinced that the researchers got it wrong.

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum Depression (1992, Sage). {ed. note – this book is now in its 3rd edition and is titled Depression in New Mothers (Routledge, 2010).}

Photo by Tristan Wallace via Flickr Creative Commons

Photo by Tristan Wallace via Flickr Creative Commons

Since writing my first book, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing:

High numbers of American women have posttraumatic stress symptoms (PTS) after birth.

Some even meet full criteria for posttraumatic stress disorder. For example, Lamaze International’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010). The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals.

“Isn’t that just birth?” you might ask. “Birth is hard.” Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009). Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011). Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does This Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences, as these
mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:

“I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.”

“The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.”

Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.

“Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.”

“My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.”

What You Can Do to Help

There are many things that lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.

  • Anticipate possible breastfeeding problems mothers might encounter. Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.
  • Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries. Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able to handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin-to-skin, babywearing, or infant massage.
  • Refer her to resources for diagnosis and treatment. There are a number of short-term treatments for trauma that are effective and widely available. EMDR is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers and even a free app for patients called the PTSD Coach. In addition, the site also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.
  • Partner with other groups and organizations who want to reform birth in the U.S. Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection (take the opportunity to view their reports on the important issues regarding birth in the US HERE) , are working to reform birth in the U.S. 2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria will be released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices. I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.

There is also a major push among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.  And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers and care providers stand together and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano, of Childbirth Connection,  describes it this way:

As we begin 2013, it is clear from my vantage point at the Transforming
Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.  

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

Here are some helpful links to share with mothers:

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president elect of the APA Division of Trauma Psychology. This post is a preview of her editorial in the Vol 3-4 of Clinical Lactation. You can read more about Kathy at


Seeking Breastfeeding Warrior Poets: Writing to Change the World

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA

In her book Writing as a Sacred Path, Jill Jepson describes four archetypes in religion and folk lore and how they relate to writers: monk, mystic, shaman and warrior. Of these four, the one that intrigued me most, and the one most relevant to writers in the breastfeeding field, is that of warrior. It’s an apt metaphor when we consider the power of words and how important they are in changing cultural paradigms, as Jepson describes,

One mark of a warrior is the knowledge that what she does can make a profound difference in the world. Because of that power, warriors are trained never to act recklessly or in malice. The writer too must live with that awareness. Like the warrior, you possess the power to alter the course of people’s lives—for everything you write, no matter how trivial it seems, might change some reader’s beliefs or impel her to act. That power makes you honor bound to write with the utmost integrity. If you are a writer, you are engaged in a battle for truth, justice and peace, whether you want to be or not. This is an awesome responsibility, but learning from the warrior, studying his practices, and following his code can help you rise to the challenge.

Pen and paper

Photo by Phil Gyford via Flickr Creative Commons

Warriors train for years to learn their craft. Yet writers often feel that they should be able to instantly put pen to paper and create something memorable. Writing, like any talent or skill, needs developing. But it’s important to start somewhere. Even our smallest efforts can make a difference for mothers and babies.

In describing warriors, Jepson offered another intriguing image: that of warrior-poet. The ancient world honored the warrior-poet: a warrior who could also tell the story. One of the first scenes in the 2006 movie 300 depicted a warrior poet, the sole survivor of the battle of 300 Spartans who held off the massive armies of Persia. The movie Braveheart also ended with reference to warrior-poets:

They fought like warrior-poets.

They fought like Scotsmen—and won their freedom.

The warrior-poet is also a fitting image for writers in the breastfeeding field. True, mothers and babies need apologists—writers who can defend and make a great case for breastfeeding, who can provide the facts, figures, and physiologic details. But that will only take us so far.

Breastfeeding also needs its bards. Writers who can see the sublime within the ordinary and capture breastfeeding at its most intimate. For in the end, it is not the facts that compel mothers to breastfeed; it’s the magic. We need writers who can convey that. I invite you to pick up your pen and become a breastfeeding warrior-poet. Mothers and babies need you.

Kathleen Kendall-Tackett is Owner & Editor-in-Chief of Praeclarus Press, Editor-in-
Chief of Clinical Lactation, and author or editor of 22 books, including How to Write for a General Audience, and author of more than 320 articles and book chapters. She will be teaching a workshop at the 2013 USLCA meeting entitled “Write to Change the World.” For more information, go to or


One Every 21 Seconds: Let’s Remember What We are Fighting For

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA

Photo via

One of my favorite movies is The Girl in the Café. It is a quirky, and somewhat improbable love story between two very lonely people, Lawrence and Gina (played brilliantly by Bill Nighy and Kelly MacDonald), who meet by chance in a café in London. Lawrence works for the Chancellor of the Exchequer (the minister of economics and finance) in Great Britain. His team is preparing to attend the G8 Summit with the other world leaders. On impulse, he invites Gina to accompany him to the G8, and she learns about the Millennium Development Goals for the first time. What she learns becomes the central focus of the rest of the movie.

The Millennium Development Goals

In 2000, 189 heads of state issued the UN Millennium Declaration, which was a plan for countries and development partners to work together to reduce poverty and hunger, tackle ill-health, gender inequality, lack of education, lack of access to clean water, and environmental degradation. They established eight Millennium Development Goals (MDGs), with targets set for 2015. One of the most important goals is MDG 4: Reduce child mortality.

Fortunately, there has been some progress here, but there is obviously more to do. Annual deaths of children under five years of age in 2009 fell to 8.1 million, down by 35% from 1990. Diarrhea and pneumonia cause the deaths of nearly three million children under five each year worldwide. An estimated 40% of deaths in children under five occur in the first month of life.

According to the World Health Organization, infant and young child feeding is a key area to improve child survival. The first two years of a child’s life are particularly important, as optimal nutrition during this period will reduce morbidity and mortality, reduce risk of chronic diseases, and lead to overall better development. “In fact, optimal breastfeeding and complementary feeding practices are so critical that they can save the lives of 1.5 million children under five every year.”

UNICEF also made a similar statement regarding deaths from pneumonia and diarrhea, the two most-common causes of child death worldwide.

We know what needs to be done. Pneumonia and diarrhea have long been regarded as diseases of poverty and are closely associated with factors, such as poor home environments, undernutrition, and lack of access to essential services. Deaths due to these diseases are largely preventable through optimal breastfeeding practices and adequate nutrition, vaccinations, hand washing with soap, safe drinking water and basic sanitation, among other measures. 

Does MDG 4 Apply to Mothers in the U.S.?

Yes, you might say, breastfeeding is important in the Third World, but not really critical in the U.S., where “safe” alternatives abound. Of course, I’ve heard all this before. But consider this. The U.S. now ranks 41st in infant mortality.  In other words, our
babies are dying too. What is particularly concerning is the large disparity by ethnic group.

According to the Centers for Disease Control and Prevention, African Americans have 2.3 times the infant mortality rate as non-Hispanic whites. They are three times as likely to die as infants due to complications related to low birthweight as compared to non-Hispanic white infants.

Infant mortality rate per 1,000 live births, 2008

Source: CDC 2012. Infant Mortality Statistics from the 2008 Period Linked Birth/Infant Death Data Set.

A key factor in these statistics is breastfeeding. In a national CDC survey, 54.4% of African American mothers, 74.3% white mothers, and 80.4% of Hispanic mothers attempted to breastfeed. Breastfeeding rates were the lowest for African American mothers in 13 states, where they had breastfeeding initiation rates at least 20% lower than white mothers. In six states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, and South Carolina), the prevalence of initiating breastfeeding among African-American women was less than 45%.

Now for some good news. As Tanya Lieberman shares in a blog posts for Best for Babes, the answer to this problem right in front of our face.

Evidence is accumulating that not only does following the Ten Steps improve breastfeeding success rates in general, it actually eliminates or significantly reduces race-based disparities.

Consider the following examples:

One study of Baby Friendly hospitals in the U.S. found that “breastfeeding rates were not associated with number of births per institution or with the proportion of black or low- income patients.” In other words, whether you had a large or small population of women who were African American, breastfeeding outcomes were the same. Disparity? Poof!

Here’s another study, of Boston Medical Center, which became a Baby-Friendly Hospital in 1999. The rate of breastfeeding among African American women went from 34% in 1995 to 74% in 1999. Yes, that’s super impressive on its face. But consider this: the overall breastfeeding rate went from 58% to 78%. So that means African American mothers were within 4 percentage points of the overall hospital rate. A study found that, “Among a predominantly low-income and black population giving birth at a U.S. Baby-Friendly hospital, breastfeeding rates at 6 months were comparable to the overall US population.” Disparity? Gone, baby, gone.

One Every 21 Seconds

In the climactic scene in Girl in the Café, Gina makes an impassioned speech to the
assembled world leaders (shortly before she is removed from the gathering), pleading with them to do something to help. She points out that one child dies of extreme poverty every three seconds. She snaps her fingers and says, “There’s one….and another…and another.”

We can make a similar statement. If we consider the WHO estimate of 1.5 million infant and child deaths annually, we can say that one child dies every 21 seconds due to lack of breastfeeding. “There’s one…and another…and another.” In the time it takes me to complete a 60-minute lecture, 171 children have died. With the U.S. ranking 41st in the world in infant mortality, this problem is not just “out there.” It is at our door as well.

We have made wonderful strides in 2012 in improving breastfeeding rates. It’s been an excellent year. Not surprisingly, there has also been a backlash. When people claim that this is matter of “upper-class white women” interfering needlessly in the lives of patients and trying to deny them “choice,” I hope you will see that they have truly missed the point. We need to continue to hold the line and remember what we are really fighting for. I long for the day when we can no longer say “there’s one…and another…and another.”

Wishing you a happy and healthy 2013. Thanks for fighting the good fight.

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president elect of the APA Division of Trauma Psychology. This post is a preview of her editorial in the Vol 3-4 of Clinical Lactation. You can read more about Kathy at


New Book Describes the Importance of Caring for Newborn Families

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA

A little over 20 years ago, I started writing for a little indie magazine called, The Doula. I was thrilled to have the opportunity. As a new mother myself, I loved that magazine. Each article was well written and spoke so beautifully to my experience. It was during that time, that I first encountered the work of Salle Webber, a postpartum doula in Santa Cruz, California. She had written about the needs of postpartum women. I quoted that article for 20 years. I was fortunate that when she decided to write a book, she got in touch with me. I was privileged to serve as doula to her first book, and I am pleased to present an excerpt from it. As International Board Certified Lactation Consultants (IBCLC) as well as breastfeeding volunteers and supporters, being in tune with the needs of women in these moments is essential. In this season of Thanksgiving, I hope it nurtures you as it has nurtured me. Enjoy!

Cover photo credit: Maggie Muir

Excerpt from The Gentle Art of Newborn Family Care by Salle Webber:

Birth is a deeply spiritual event, mysterious and miraculous. At the same time, birth is profoundly physical, with pain, blood, risk, and no guaranteed outcome. A new mother and her infant are a holy couple, inspiring reverence in all who come near. Yet they are delicate, depleted by the exertions they have undergone, and touched forever by the nature of their birth experience. They require careful attention to their physical bodies, bacteria testing, as well as sensitivity toward their ever-changing emotions and needs.

A father has a somewhat different path. He has a more intellectual idea of the child, not experiencing the intimacy of sharing his body. Not only is he now a father of a helpless infant, but his wife or partner has become someone else. The new dad may feel overwhelmed with responsibility. He may feel that his own needs are pushed into the background, and his best friend has a new love–the baby.

Author Salle Webber

Parents need care as they make this huge transition. The life change that a seven-pound infant can generate is surprising. In the first few days postpartum, mother and baby will mostly be snuggled in bed together. The mother should be encouraged to get up only when she feels like it, and provided with food and drink. One wonderful female doctor recommends, especially after surgical birth, two weeks in the bed, two weeks on the bed, and two weeks near the bed.

Try to create an environment that is restful to eye and soul, that will allow the new mom to dwell on the beauty of her child without material distraction. It is also helpful to see that the things she needs, such as her water, a snack, phone, magazine or book, are in easy reach. These simple acts will make a big difference.

Sharon is a rock in her community, one who others come to for advice and support. When she delivered her third child, it was a difficult birth. She lost a significant amount of blood, and was physically and emotionally exhausted. As her doula, I found her in bed looking quite disheveled and uncomfortable, her older children appearing lost without the attention of the capable and devoted mother they were used to. I herded the kids into the kitchen, fixed them breakfast, and went back to Sharon. She was instantly relieved to have a bit of the pressure taken off, and said she wanted nothing more than to sleep. I bundled her newborn girl onto my chest, threw a load of laundry into the washer, and moved the energetic youngsters into the other end of the house. I engaged the older children in drawing, then in the game of sorting laundry. They played outside for a while as their mom slept deeply. About the time the baby began to stir, Sharon awoke, feeling that tingling in her breasts. After a session of nursing, I brought her a tray of warm and nourishing food. I held the infant while she ate and checked in with her other children. Friends came by to invite the older ones to the park to play. Once the house was quiet, Sharon took a leisurely shower, during which time I changed her sheets and tidied up her bedroom. She returned from her shower and uttered a cry of joy to see her bed so welcoming! Little things mean a lot at times like this. She crawled right in.

It took two weeks for Sharon to begin feeling well, and she spent her time close to her bed. I worked to ease her burden by tending the other children’s needs, keeping the laundry moving, and holding her baby. I encouraged her to take care of herself, to enjoy long showers and good food and drink, and to allow members of her community to assist her family by bringing meals, entertaining the children, helping with shopping, and stopping by for an hour to do whatever needed to be done. Many women are so used to taking care of everyone else, they hardly remember how to honor their own needs. It was a reminder for Sharon that we all need each other, and she surrendered gracefully to the demands of her own body.

The art of being a doula lies in a compassionate and nurturing heart, a willingness to serve others, love of family life and babies, and a healthy respect for the work of the home. This is holy work. We are laying the foundation of this family’s life with this precious new addition. We can help to bring harmony, calm, humor, and rest. I encourage every postpartum care provider to consider what it is she wants to model. I believe the experiences of infancy are vitally important in the development of the deeply held mental structures with which we respond to life. As we demonstrate relaxed and contented behavior, we impart these feelings to the child as well. How better to serve the future of humanity?

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at


First, Do No Harm: A Critique of Recent Research on “Controlled Crying” (Part 2)

Earlier in the week, we presented Part 1 of a commentary from Kathleen Kendall-Tackett on a recent study about the long-term effects of controlled-crying for infants. As infant sleep and breastfeeding are so closely tied together, we are so glad to share both Part 1 and Part 2 with our readers.  

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA 

Does Controlled Crying Cause Long-term Change to Cortisol Levels?

Critics of controlled crying have expressed concern that this technique alters infant cortisol level. To address this concern, the authors assessed the children’s cortisol levels at age 6 and found no significant difference between the intervention and control groups. Unfortunately, these findings alone do not mean lack of physiological harm. We need to look at short-term effects.

The question we need to ask is what happens to babies when their mothers do not respond to them? One way this has been studied is by examining the impact of maternal depression on infants. Maternal depression impairs mothers’ ability to respond to their infants’ cues, and raises Infant cortisol levels (Feldman et al., 2009). Even when non-response is temporary, babies still find it stressful. In the still-faced mother paradigm, mothers are asked to not respond to their infants’ cues in a laboratory setting. This research is designed to mimic the effects of maternal depression. The still-faced-mother experiments increase babies’ cortisol levels (Grant et al., 2009).

So why the concern about cortisol? Mainly, it’s this: cortisol is quite toxic to brain cells. If cortisol is elevated for short time, it likely causes no damage. But if cortisol levels are repeatedly elevated because the infants are experiencing long and repeated incidents of being ignored when they cry, it can be a problem. The brain is at its most vulnerable in the first five years, so soaking the developing brain in cortisol is not a good idea (Buss et al., 2012).

The lack of difference between the groups at age 6 does not mean lack of harm. Cortisol levels likely returned to normal in the intervening five years, unless there was ongoing adversity. Unfortunately, cortisol elevated in infancy could have still affected vulnerable brain cells, even if current levels are normal. The authors would need to use more sensitive measures to assess these potential changes.

What About Breastfeeding?

Photo by Alessandro Pinna via Flickr Creative Commons

The final limitation of this study is rather stunning. Price et al. did not measure the effect of infant feeding method on sleep or maternal depression. Yet feeding method has a direct effect on both maternal sleep and postpartum depression, which are the two main factors the authors claim to address with their sleep intervention. Exclusively breastfeeding mothers get more sleep and are less likely to be depressed than their mixed- or formula-feeding counterparts (Doan, Gardiner, Gay, & Lee, 2007Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a2009bKendall-Tackett, Cong, & Hale, 2011).

Given these findings, isn’t it strange that breastfeeding was not even enquired about? If the study was conducted in a country with low breastfeeding rates, this omission would be somewhat understandable. But it makes no sense coming from a country like Australia, which has one of the highest breastfeeding rates in the world.


So what can we take away from the Price et al. study? Should we recommend the controlled-crying technique to parents? Based on the limitations of this study, I do not recommend this approach. The sample size is small, the follow-up sample is missing the children most likely to be negatively affected, their assessment of the intervention did not account for the Hawthorne/placebo effect, they have not measured dose of the intervention, nor have they accounted for feeding method, which recent research has soundly demonstrated as being related to both variables that are of key interest: maternal fatigue and postpartum depression.

My objections to this approach are not new. When I first encountered the Price et al. study, I remembered a study that this same group of researchers published 10 years ago in the British Medical Journal demonstrating that controlled crying lessened the risk of postpartum depression (Hiscock & Wake, 2002). I was specifically struck by this response from a German physician (Perl, 2002):

“As a German, I am unhappy to find fairly undiluted ideas of militaristic Nazi infant care uncritically repeated by these Australian care providers. The Nazis understood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990s completely escaped the authors’ notice.” 

In closing, Price et al. stated that organizations, such as the Australian Breastfeeding Association, were unduly negative towards controlled-crying techniques and need to update their recommendations based on more current research. Given recent findings in neuroscience, childhood trauma, breastfeeding, and maternal sleep, which are not accounted for in the Price et al. study, I’d respectfully advise the authors to do the same. I’d further urge healthcare providers who are considering recommending controlled crying to consider the limitations to the current study and alternative approaches that can meet the needs of both mother and baby.

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at



First, Do No Harm: A Critique of Recent Research on “Controlled Crying” (Part 1)

Today, we present Part 1 of a commentary from Kathleen Kendall-Tackett on a recent study about the long-term effects of controlled-crying for infants. As infant sleep and breastfeeding are so closely tied together, we are so glad to share this with our readers. Check back on Thursday for Part 2.

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA 

A recent article in Pediatrics (Price, Wake, Ukoumunne, & Hiscock, 2012) reported on the long-term effects of a controlled-crying intervention for parents of infants 8 to 10 months old. The children were assessed five years post-intervention and showed no apparent harm. The media response to these findings has been overwhelming. Could this be the answer that weary parents have been waiting for? The authors certainly thought so. In fact, they concluded that practitioners could “confidently” recommend this approach.

Before we proceed, let’s step back and consider whether this recommendation is warranted. We must critically evaluate both the current study and where it fits within the larger literature in maternal-child health. In my view, there are a number of serious limitations to this study that call into question whether we should recommend this practice to parents.

Study Limitations

The Cumulative Effect of Childhood Adversities

Context is important to consider when evaluating potential harm caused by a parenting technique. In other words, how many parental missteps does it take for children to show evidence of lasting harm? Fortunately, children are resilient and don’t require perfect parenting. However, chronic bad parenting does harm children and the effects are cumulative (Centers for Disease Control and Prevention, 2010).

So does controlled crying cause infant harm? If it occurs in families with generally warm, responsive, and loving parents, probably not. I am more concerned about the impact of controlled crying when it takes place in high-risk families. A full 31% of the Price et al. original sample was lost to follow-up, most of them “high disadvantage.” In other words, the group most likely to be negatively affected by controlled crying was not in the follow-up study.

Assessing “Dose”: The Chronicity and Severity of the Experience

When assessing potential harm of a practice, it’s also important to consider chronicity and severity. This is a way of factoring in “dose” of an intervention. In terms of infant sleep, we need to know how often controlled crying was used in an average week, how many weeks or months that the parents employed these techniques, and in an average episode how many minutes elapsed before the parents responded to their babies. The longer they used it, the more pronounced the effects.

Information about “dose” was totally absent from the Price et al. study. From their article, we know little about what the parents actually did in either the intervention or control group. Even beyond the research protocol, parents could have implemented a controlled-crying program for themselves. We have no way of knowing. Given the wide range of practices that likely occurred in both the “intervention” and “control” groups, I am again not surprised to see no significant difference between groups.

Was the Intervention Actually Effective, Even in the Short Term?

Another problematic aspect of this study has to do with the research design’s inability to account for the Hawthorne Effect. The Hawthorne Effect was first noted by industrial psychologists who were testing the impact of minute changes in illumination on productivity in factory workers. When they raised the level, productivity increased. When they lowered the level, productivity also increased. In other words, any intervention was described as helpful. It’s basically a placebo effect for behavioral interventions.

The Hawthorne Effect could also be behind the positive results for the controlled-crying intervention. In earlier articles, the authors reported that controlled crying lowered rates of maternal depression and improved infant sleep. Did it? Perhaps it was simply a matter of the mothers having someone to listen to their concerns. A better test would have been to compare it to another intervention (such as educating mothers about the developmental normality of infant waking at 8 to 10 months, and brainstorming about ways the mothers could get more rest and cope with fatigue).

Check back on Thursday for Part 2 of this commentary. 

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at


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