Sunday, October 25, 2009

Teaching a mom to fish, leading a mom to water

So as you may know, I completed my three-day postpartum doula training through DONA a few weekends ago. This is just one step of the certification process, but it's the biggest one, and I enjoyed it thoroughly. I was worried about being away from my daughter for so long - over 12 hours every day, including the commute, but she was a total champ, and I think it was good for her and Daddy to spend so much time together. I was also pleased to see that I can still pump a good amount of milk, at 18 months, which I did in a corner of the conference room every 3 hours or so.

We learned an incredible amount in such a short span of time - it would be ludicrous to try and reproduce or even summarize it here. The underlying refrain we kept coming back to, no matter what the topic was (infant bathing, nursing, integrating older siblings, addressing postpartum depression, light housekeeping) is the phrase "maximizing self-sufficiency". Sounds a little bit corporate speak, right? A little approved-by-committee? Yep, I get that - but it's also pretty spot-on, and really helps to distinguish a huge part of how postpartum doulas are different from, say, housecleaning services or babysitters or even "mother's helpers". There IS some overlap, some grey area, with those services, and we will often be doing a bit of all those things.

Part of the difference does have to do with additional training in breastfeeding, recognizing postpartum depression, and overall postnatal recovery. Part of it is the multifunctional nature of it, since we do a little bit of everything, including some grunt work (especially at first), but there's more to it than that. It's much more about helping the family to slowly become more and more capable of doing all these things on their own, focusing on how best to support the new, confident mother. At first, the job may involve doing the laundry pretty regularly. But then, what happens when the term of employment is over, and mom never figured out how to work it into her routine, and doesn't know what settings and products are best for the cloth diapers and baby clothes, and hasn't worked out a trade-off with her partner on laundry duty? When the doula departs for good, and hasn't addressed that, she's just leaving a void where her services used to be. She just made the family dependent on her for doing their laundry, and now what?

So it's the classic adage, made maternal: if you give a mom a fish, she eats for a day. But if you teach her how to fish for herself, she eats for a lifetime. And at first, just getting her to eat for a day may be the most important thing - but the long-term needs to be kept in mind. This was a really important revelation for me.

It was also interesting/amusing/embarrassing to see just how many things I had done DEAD WRONG with my first very unofficial client that I had taken on the week right before the workshop. (I had put the word out that I was going to be seeking practice clients soon, and this mom needed help, so, I figured, why not? She knew I was pre-training, and was happy to pay the extremely reduced rate, and just needed the extra hand.) For one thing, we are never, ever to install car seats for clients, for what in hindsight are obvious liability issues. D'oh! But in the moment, that's what she needed done, so I just went ahead and did it. For another, we are never ever ever ever to drive the children anywhere. No way, no how, for even more obvious reasons. That one I could really smack myself for, but in the moment, again, she asked if I would just drive the loaded-in kiddos (four total, including the new wee bairn) around the block a few times while she got dressed before departure for an outing, and I just said, "Okay, sure!' GAH, when I think of what could have happened . . . but now I know better. There were a few other instances too, more benign than those examples but still a little off from the postpartum standard of practice. Ah well - I feel all the more professional now.

Now for the other adage - one that is considerably harder. I'm working with my first 'real' client now (still part of the certification process, but post-training), and wouldn't you know I get a HUGE challenge right out of the gate. This mom is working on breastfeeding after a reduction, and is having some serious challenges. I am having a really tough time with the limitations of our scope of practice as doulas. We do have training in the basics of breastfeeding, but anything even slightly out of the ordinary and we are to refer, refer, refer. Well, she's already seen a lactation consultant, but frankly, either this LC is terrible or mom is not quite following the directives. Whichever one it is, I am really struggling against what I suspect is some bad information, and what I know are some counterproductive practices. So I'm already frustrated with how my hands are tied as a doula when it comes to breastfeeding. So much so that I'm thinking more and more about becoming a lactation counselor (and maybe eventually an IBCLC), but that's too far in the future to help me now.

I want to encourage this mama more than anything, but I CANNOT push her. I'm not sure I should get into the specifics here due to client confidentiality issues, but suffice it to say, I am doing my best to offer as much good information as possible, and making it as easy as possible to organize their lives around the practices that will support nursing - and her supply - as much as possible. One of the hardest things is having had the extreme difficulty of my own nursing experience and NOT sharing the information that I learned from that experience with her. DONA really drilled this into our heads, too -it isn't about us.

I understand the values and the rationale behind that, and with why keeping that in mind is important, but honestly, it's just not possible to remain 100% pure about that. If we learned a trick that was really useful in diaper changing, of course we're going to teach that to our clients, so why would I not be able to offer coaching in using a Lact-Aid, for example? So yes, I've broken the rule a bit already, despite my efforts to keep personal experience minimized and focus on information from expert sources (I bring printouts of articles and other handouts to pretty much every visit).

After our third visit, I got in touch with my own brilliant guru of a lactation consultant, to bounce some things off her. She had some great specific advice, but more importantly, she recommended making the mother state aloud exactly what her goals are - because, honestly, I never actually asked her what they were, specifically. It wasn't on the DONA questionnaire that I gave her. Perhaps no one had asked her this. A rookie mistake, maybe, but when she said this, I realized that I had been approaching this as what *I* would do, according to what MY goals would be, instead of having her articulate it to me, and for herself. Big difference.

And then, she said, the path is to ask yourself each step along the way: "Are the steps I'm taking now steps that will get me closer to my goal, or further away from it?" I remember having to ask myself that every day - every feeding, even. So I asked her to state what her OWN goals were (it was in the context of reviewing a questionnaire, so it fit perfectly & didn't feel confrontational). She right away distinguished what she perceived as "Ideal" vs. "Realistic", which I thought was revealing, and we took it from there.

The BFAR book is titled "Defining Your Own Success", and it's a double-edged sword, of a concept, in my opinion. Some women post-reduction may REALLY try everything and still not be able to produce 100% for their babies. So for them, it's important to be okay with redefining success for themselves, and not feeling like a failure because they are not able to exclusively breastfeed. I absolutely get that. But the flip side of that is that some other women are going to set such low expectations and even hopes for themselves from the beginning, that, as we can see, completely undermines and possibly even sabotages their efforts and intentions from the beginning.

So if my LC's process is to be followed, as long as every day, the mother consciously takes the steps she knows she needs to take in order to move toward her goal, THAT is success. That's defining your own success with integrity. There's nothing to feel guilty about if you've taken the steps towards your own goal, whatever that might be, and it doesn't work out perfectly for reasons you cannot control. If you know the steps you need to take for your own goal, whatever that is, and are not willing to take them, well, then, that's a little different. So I want to make sure that she is as well-informed as possible, and that she herself is clear on her goals, and that she herself is clear on the steps that are to be taken, in her own mind.

So my revised plan with my client (who I really like and respect, incidentally) is to try to keep reminding her of her own goals and the steps that we identified together as the ones that are most supportive of her ideal, and continue trying to integrate those steps into her daily life. And the biggest personal challenge for me is to not take it personally when she makes different choices - and remember that (here's that second adage) I can lead her to water, but I cannot make her drink. I can help her find the best water there is, I can put it into beautiful glasses with ice cubes and fresh lemon wedges, I can create a comfortable place for her to sit and have the water . . . but I cannot force her to drink it.


  1. That "leading to water" has been uppermost in my mind lately. I can offer my advice, send books, drop hints, and outright say my opinion, but that's where it can't make anyone drink. (Repeat to self: empowerment, empowerment, empowerment.)

    I love your lactation consultant's question suggestions. Do you know if she asks every mom about her breastfeeding goals? I have been thinking about trying that with moms I work with, to get a better idea of what we're working toward (am I sinking a lot of effort into exclusive BFing when her goal is mixed feeding? is she thinking 1 month is all she wants to do, and no one has educated her about long-term benefits?)

    If you still want to e-mail me, I responded to your comment on my blog!

  2. Glad to hear that great minds think alike!

    I think a good follow-up question (IF POSSIBLE) to asking what their goals are, is "And how did you come to that decision?" Very Official DONA Training of me there, but I think it could be quite useful and nonjudgmental. That way you can suss out if they decided to do mixed feeding because her mom did it, or only wants to do a month because she has to return to work or what have you. That way it could open the door to offering other information.

    Easier said than done, though. I think asking about goals is valid no matter what, but obviously three weeks into a breastfeeding relationship, it makes changing course a major uphill battle. I really want to try and establish relationships with future clients as early as possible - prenatally, ideally.

    Yes, I'd still love to email you - I just checked your blog & don't see the comments there yet, though . . .

  3. Anne, wow... looks like you learned so much! I am so excited for your journey. AND glad that Lily was a little trooper throughout!

    RANDOM question: Have you ever come across any thought-provoking/insightful/interesting games/activities for a baby shower? I am in charge of the games at Laura's baby shower this weekend & don't really want to just do the toilet paper circumfrence game.

  4. Kate, are you familiar with the diaper candy game? When I found out about it, I INSISTED that they include it at my shower. It's not for everyone . . .

    So, you take an assortment of chocolate candy bars - the Halloween size is ideal, actually (hopefully non-Nestle ;^D ), and a corresponding number of diapers. Unwrap and put a different candy bar in each diaper, and melt in microwave, then smoosh it around a little. Number the diapers and make a top-secret answer key with the type of candy in each diaper. Pass the diapers around in a circle, and have each participant taste the candy to try and guess which is which (they should have a piece of paper to write them all down). Hilarity ensues! If you're as amused by the kitschily gross as I am, anyway.

    It does require using a few disposables but hey, it's a party. Use Seventh Generation or Tushies unbleached/gel-free and give her the leftovers!

    Man, I wish I could be there! Please give Laura my absolute best! (And tell her to check her email - I had a follow-up question for her. She should know what I mean.)

  5. Hmm, maybe they take a while to show up. Anyway, publichealthdoula At gmail is my newest e-mail address (eventually I'll be up to an even dozen!)

  6. I totally hear you on this. I have tried to tell myself over the last year or so "You can lead a horse to water, but you can't make 'em VBAC!" That's what I have to say to myself every time somebody begs me for information/help/support on VBAC and then goes and schedules a cesarean anyway. It bums me out so much, but I really should not care. It ain't my cesarean! Although I think my PTSD causes me to relive every one else's cesarean as if it's my own. I know... it's messed up.

    Anyway. I get it. But it sounds like you're doing a really great job of being objective.

  7. Great post, Anne! One of the ways that my various trainings have helped me to incorporate my "own personal experiences" with the whole "ethics" thing is to simply say "Many moms have had success with XYZ" or "There are plenty of moms who have expressed that concern as well" which allows me to impart my personal knowledge without it being about me specifically, and the stating allows the mom to decline without feeling like they have snubbed me personally! You'll find just the right balance for you and for your families! No one does it 100% right every time...we adjust our approaches for each situation and try our best. <3

  8. Thanks, TFB. I can definitely see this being a recurring refrain for you, too!

    Justine, I really like that approach! How perfect, really. I mean, I don't have to explain that *I* am one of those "many moms", right? I am definitely remembering this one. THANK YOU.