“You Are Not Alone”: Toward Equity in Breastfeeding and Skilled Lactation Care

Introduction

In preparing for this address today, I couldn’t help but reflect on all of the people who have helped me and nurtured me along the way. I am deeply grateful to all of my mentors. Although they are far too numerous to name each 1, I want to thank them all.

I also want to thank the founding members of ILCA (International Lactation Consultant Association) whom we celebrated last year as well as all the former presidents and board members. As we stand here today and celebrate successes and look forward to the future of the International Lactation Consultant Association, we must remember that as 1 of the longest standing breastfeeding organizations, we are here because those before us had the courage to stand up for breastfeeding when no one else would. Before we had the science we have today, we had dedicated breastfeeding advocates who made the commitment to begin something extraordinary. We have the responsibility to continue to build on what came before us.

Next, I want to take this opportunity to extend my deepest gratitude to ILCA’s current board of directors. I thank them for their collaborative and thoughtful approach to governance and leadership and for their confidence in me to serve as ILCA’s president for the next 2 years. I also thank ILCA’s executive director for his vision and leadership. His exemplary leadership also extends to a most capable staff. In addition, ILCA could not do our work without our contracted staff, our media team, our education coordinator, and the editor of the Journal of Human Lactation. Last but far from least, I offer our volunteers, who serve as committee chairs, executive teams, international liaisons, advisory committee members, and our conference volunteers, an enormous helping of gratitude. We simply could not function without our volunteers.

I also have 1 more very special thanks to give. I want to extend the most heartfelt gratitude to ILCA’s immediate past-president, Decalie Brown, for her contagious and joyful spirit. Decalie exemplifies everything good that our profession has to offer—not only a highly skilled nurse midwife and IBCLC (International Board Certified Lactation Consultant) but perhaps more importantly, she is caring, warm, and capable of easily connecting with others.

Human Connection

This is what I would like to focus on this morning—the concept of connection. I want to focus on connection because I think it is fitting in several ways.

First, it describes something that we all care so deeply about. It describes the unique breastfeeding mother and child relationship—2 individual human beings who are inextricably linked, biologically and socially. Through complex mechanisms, the breastfeeding connection provides 1 critical foundation for human beings to thrive equitably across the lifespan and across generations. This relationship represents just 1, but 1 critical foundation of human connection. Next, connection also plays a critical role in the work we do as IBCLCs and others who provide skilled lactation counseling and care. The care we provide to families supports this critical human connection. Finally, we also connect to each other as professionals. It is certainly my own experience that being at the ILCA conference and other events stimulates a sense of excitement and renewed energy about this work. This is not just a social connection that we share. When we feel this excitement and we feel drawn to others, stimulated intellectually and compassionately, our brains are connecting. It is through these connections as individuals or members of ILCA that we become part of a much bigger picture.

The bigger picture is illustrated through ILCA’s vision, “Transforming world health through breastfeeding and skilled lactation care.” We work toward this ultimate vision through ILCA’s mission, “to advance the International Board Certified Lactation Consultant profession worldwide through leadership, advocacy, professional development, and research.” ¹ Today, I am going to talk about how connection is vital to attaining ILCA’s vision. To realize our vision, we will need to create change. We do that through advocacy. I also believe that in order to change the world, we must change ourselves first. So for now, I want to continue our exploration of connection by drawing you into a story—first, my personal story, and then, ILCA’s story.

My Story

I want to tell you my story, which cannot be separated from my ancestors. Thanks to the burgeoning field of epigenetics, we now understand how our life experiences shape us as individuals. We now know that human beings are shaped by a complex interplay between our genetic codes, our environment, and our experiences. These experiences become embedded in our DNA, passed down from 1 generation to another. In this way, we can inherit our mother’s facial features but we can also inherit her character. These inherited factors accumulate and can become advantages or disadvantages. The complex interplay between biological and social factors together generates population patterns of health and disease, well-being, and also social inequities in health.

I think my love and passion for maternal child health is in my genes. Thus, I begin my story with my grandmother, Catherine Kennedy, my mother’s mother. She was 1 of 5 daughters born to Irish immigrants. She was a nurse, graduating in 1929. I adored her and when she passed away just 5 years ago at the age of 103, I inherited her diary. I was fascinated but not surprised to read that during her training, her favorite place to be was in the nursery with the babies. I also remember her telling me a story of the great flu epidemic of 1918. When she was 10 years old, her mother, having just weeks before giving birth to her youngest daughter, had taken ill with the flu. She remembered the doctor who came to the house telling her mother very sternly, “Do not give that baby anything but your own milk.” These stories, among others, created lasting impressions on me.

Next, I want to introduce you to my great-great grandmother, on my father’s side. Her name was Odilla Monette. I learned several years ago that she was a midwife in the rural eastern township region of Quebec, Canada, and then in the northeast kingdom of Vermont. She moved to Vermont to care for my grandmother and her 9 siblings after the death of my great grandmother and 3 of my grandmother’s siblings due to an outbreak of typhoid fever. They all died within a few days of one another, a very interesting and also heartbreaking discovery for me as a public health professional.

The expression of my genetic code closely resembles my mother’s. From childhood, I can remember people commenting on the remarkable resemblance between us. “You look exactly like Ginny!” they said, and still do. Ginny was a fiercely protective mother of 3 daughters, and between my grandmothers, aunts, cousins, and my mother, I learned at an early age that women are powerful nurturers of families. I have been a passionate advocate for women and children’s health and rights issues for as long as I can remember, as are my 2 sisters.

Although I did not look like my father, Ron Fortin, growing up I was exposed to his great love of science, and I think as a result, I am very much drawn to science, like epigenetics. He also sang in a folk group during the civil unrest of the 1960s in the United States, so my sisters and I were raised on protest songs. I definitely did not inherit his beautiful singing voice, but I sure learned a lot of song lyrics that spoke to social justice and a system of values that honored all human beings as equal.

So was it coincidence that in the third grade, I chose Florence Nightingale as the subject of my biography fair and that I am finishing a PhD in nursing today? Was it a coincidence that I became a labor nurse in the 1990s and, during a resurgence of breastfeeding behavior in the US, had a strong desire to nurse my babies, because I believed that it was best for them? Was it coincidence that my own challenges with breastfeeding led me to want to learn more so that I might help other breastfeeding families? When I learned more about unjust social barriers that restrict or prevent women who want to breastfeed from breastfeeding, was it a coincidence that I chose to study unjust social barriers to breastfeeding as the focus of my dissertation research?

Although I was not breastfed, my 2 sons were exclusively breastfed for 6 months and weaned when they were over a year. We live on the shoreline on the east coast of the US, halfway between Boston and New York, and my children’s experiences have begun to shape them. We as individuals, like all of you, contribute to populations. When we observe populations, we see patterns begin to emerge, for example, patterns of breastfeeding rates. Likewise, individual members of ILCA contribute to the larger group that is our profession, and when we observe professions, we also begin to see patterns emerge. Each 1 of you is a part of ILCA’s story.

ILCA’s Story

ILCA’s story begins with a shift in its vision 2 years ago, followed by the intentional and formal adoption of 3 values that underpin every idea, decision, program, and initiative undertaken by ILCA. These 3 core values are knowledge, diversity, and equity. First, we believe that knowledge guides our practice, strengthens our value, and supports our role in transforming global health. Second, we foster an inclusive environment that supports leadership, advocacy, professional development, and research from varied perspectives. Third, we support global access to the IBCLC profession. Of the core values, I want to focus on equity for a moment.

ILCA’s equity statement addresses 2 areas: equity in access to skilled lactation care and equity in access to the IBCLC profession. What do we mean when we talk about equity and inequity in health care and lactation? First, a clarification—I use the word inequity deliberately because there is a distinct difference between inequality and inequity. Inequality is not necessarily unjust but inequity denotes a condition that is unjust. ² For example, rates of prostate cancer are unequal between men and women but this is not unjust. However, the difference in breastfeeding outcomes across populations around the globe is unjust and leads to lifelong inequities. As we just discussed, those inequities become encoded in individuals, influencing generations to come.

Let me be clear—there are inequities in breastfeeding rates that cannot be explained by biological factors alone. In the US, women and children who are marginalized by race and ethnicity have lower rates of breastfeeding. ³ Experiences of racism, the subject of my research, have been identified by a very large body of research as an underlying cause of poor health outcomes in the US. ⁴ Most notably, perhaps, are poor birth outcomes, including preterm birth and low birth weights. ⁵ But outside of the US, unjust differences in breastfeeding behaviors are apparent as well. Social factors related to gender, caste, class, geographic location, and country of birth predict breastfeeding practices. ⁶

Addressing Inequity

The landmark US report Unequal Treatment identified the connection between health disparities and differences in treatment according to race and ethnicity, by health care professionals. ⁷ A large body of evidence demonstrates that bias leading to discrimination by health care providers is a root cause of health inequities.^8,9 Although research is limited, we have every reason to believe that this is also possible for breastfeeding outcomes. As health care professionals, we want to believe that we do not contribute to discrimination. Unfortunately, prior research demonstrates otherwise. As 1 speaker so thoughtfully shared with us in her presentation on Friday, bias is complex and affects us all, regardless of good intention, and that bias leads to discrimination. Whether intentional or not, it causes harm.

Until we thoroughly address bias in access to our profession, historically marginalized mothers and infants will continue to bear the inequitable burden of lower breastfeeding rates. These lower breastfeeding rates will mean compromised opportunities to thrive across the lifespan. The same unjust social mechanisms that prevent or restrict women from breastfeeding also prevent people from entering our profession. We have heard from people around the globe these past 2 years who have experienced barriers in their desire to enter the lactation field. Barriers expressed have to do with factors including educational requirements, finding qualified mentors, language barriers, financial constraints, and institutional oppression. ¹⁰

Members of our community who have faced these barriers should not have had to bring them to light. Now that they are in the light, we must address this issue. I would like to express my gratitude to all of our community members who were brave enough to start the conversation. I promise to continue to do the personal work necessary by those of us who are members of socially dominant groups to participate fully in making the changes that are necessary, for no other reason than it is the right thing to do.

The right thing isn’t always the easy thing, but the right thing is the meaningful thing. So it is our values that guide our work. We know that, collectively, we make up the profession and our professional patterns influence the health and well-being of mothers and children worldwide. These are our professional values; they are mine and they are yours and, as 1 of my wise fellow board members expressed to me just the other day with regard to our profession, “No one gets to leave. Everyone has to stay. We have to figure this out together” (M. Kadeshe, personal communication, July 19, 2016).

Equity Through Connections

How are we going to make changes that promote equity for breastfeeding families and for access to our profession? The essence of advocacy work is about people gathering together around a good idea. We already have the good idea: Improving world health through skilled lactation care is the good idea. Increasing access to the profession is the good idea. We have already begun to make changes and we are seeing results, and I am really excited about the direction that ILCA is moving.

For starters, the coalition model is one that resonates with many because it appeals to underlying values, like ILCA’s values. It specifically encourages people to collaboratively seek solutions to problems that would be far more difficult to solve by any 1 single person or entity. One example of coalition impact is ILCA’s attendance at the Women Deliver conference in Copenhagen this past spring. Together, ILCA, the Academy of Breastfeeding Medicine, Helen Keller International, 1000 Days, UNICEF, and the World Alliance for Breastfeeding Advocacy (WABA) were part of a panel that presented information to journalists from all over the world about specific areas of expertise and advocacy opportunities. I took the opportunity to present information about the importance of skilled lactation support and I used the example of support among families who have been forcibly displaced from their countries.

In addition to Women Deliver, ILCA reserved funding to send representatives to the 61st World Health Assembly, where we submitted a statement on Code protection. As is the case each year, ILCA as a core partner of WABA participated in the development of the World Breastfeeding Week (WBW) materials. As another example of connection, the theme of WBW connects breastfeeding to the newly adopted Sustainable Development Goals (SDGs). The SDGs are the direction in which global breastfeeding advocacy is going.

Essentially, ILCA’s Global Partners Initiative also represents the formation of a coalition. As a founding member of my state coalition and as its chair for 9 years, this is something I feel passionately about. We can only accomplish change if we work together. Just this week, we held our second Global Partners Meeting and we had the opportunity to begin to develop strategies that will positively influence change. By organizing this forum, we provided a bridge between our global partners and the global agendas described by the World Health Organization, WABA, and the Breastfeeding Promotion Network of India.

We will not achieve equity unless we have representation from groups all over the world. As a show of my vulnerability and cognitive dissonance, I only just realized that the IBCLC credential does not translate in all countries. Of course, this makes perfect sense, but until I heard it, I hadn’t even considered this. This is a sign of the automatic thinking that was presented yesterday. This is why the partner program is so important. Translations of materials are just 1 example of how this advocacy work moves us toward equity. ILCA currently has 21 partners spanning the globe, and just this year, we added 6 new partners. One of the benefits of our partner program is that we provide 1 conference registration for each partner and a table in the exhibition hall, among other benefits, such as access to ILCA’s International Code Committee. If you are interested in becoming an ILCA partner, I urge you to speak with our executive director; his contact information can be found on ILCA’s website.

Another change that supports equity is our new pricing for membership. As a measurable outcome or result of the newly adopted membership pricing, our memberships in category B, C, and D countries have increased by 230% this year. Equity pricing was extended to our live streaming for this conference, and I am happy to report that more than 20% of our participants here today took advantage of that option.

Next year, our conference will bring you elements of each of our core values: knowledge, including clinical skills and leading edge research; diversity, including your opportunity to connect with the leaders in our field from around the globe; and, equity, and our collective efforts to increase access to breastfeeding and to the profession. Finally, our amazing team is working around the clock to be able to deliver a platform that will help to connect you with each other. We want and need you to be able to connect to the incredible knowledge and experience, education, and advocacy resources that all of the new partners, and long-term members, have to offer. Watch for a new way to build and participate in the online community at ILCA. But how does the global agenda impact you, the individual member on the ground?

Conclusion

If I haven’t convinced you yet that we’re all connected, then I want to bring us back now to my story at the beginning. I want to acknowledge that my story is one of connection but not just to my own family. A critical lens exposes not only what is there, but what is “not.” To that end, I am here today because I have benefited from a system that paved the way for me to become a nurse, an IBCLC, a PhD student, and the president of ILCA. My children are strong and healthy because they benefit from everything good that society has to offer, including exclusive breastfeeding. When we, as individuals from historically dominant social groups, are willing to acknowledge our participation in this system, we create the space for change. To ignore these issues is a privilege. We can move from shame and guilt and a feeling of helplessness to inward reflection and, ultimately, action. This will require a willingness to accept vulnerability through humility.

Our profession is vulnerable as well, and herein lies our opportunity. How will coalition building, and addressing inequity, impact your work in your local community? The individual impact and the population impact are connected and inseparable. When you as an individual support ILCA’s global advocacy agenda, you are directly transforming world health through breastfeeding and skilled lactation care.

I want to ask you now to please take a moment to look around the room. Look at the people beside you, in front of you, and behind you. If you think about all of the events that had to happen through time—your parents had to meet, your grandparents, your great grandparents, and so forth, all the way back to the beginning of time—if you think about it this way, it is exceedingly unlikely that we are here at all, much less here together, in the same room at the same point in time. In keeping with this consideration, a quote frequently attributed to Hillel the Elder reads, “If not us, then who? If not now, then when?” What you do back home is what will transform world health. Sometimes it can be isolating; we get busy and may feel discouraged and we forget that we are part of the bigger picture. If that happens—when that happens—remember at this moment, you were not alone.

Thank you, and I’ll look forward to connecting with you.