Get Ready, Illinois!

Continuing the Journey

Carole Peterson MS, IBCLC

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Fall 2014 WIC Workshops

• October 14 Mount Vernon, IL

• October 15 Springfield, IL

• November 14 Naperville, IL

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WELCOME

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LET’S HEAR ABOUT EACH OF YOU

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What ideas did we work on?

• Some of the ideas

• NWA Six Steps

• Breastfeeding duration

• Peer Counselor support

• Marketing our breastfeeding services

• Baby Behavior training

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Let’s start by looking at your surveys

• Breastfeeding Practices Survey 2014

• What did we learn?

• What did we try?

• What else can we do?

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Questions 2 and 3

• Protocol for contacting moms 1 week prior to delivery

• PC contacts based on reports

– Usually by phone

• Tickler file

• No protocol

• Some agencies are able to contact 100%, attempts at least

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What has worked

• Developing a protocol

• Involving PCs

– In classes

– Face to face opportunities

• Texting

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Implementation strategies

• Follow up meeting with administration

• Working with the hospitals

• Include PCs in classes, clinic flow and face to face contacts

• Reminders to moms about skin to skin and laid back breastfeeding

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Question 4

• Protocol for contact week after delivery

• Why is this essential?

• How quickly can we do this?

• Mothers doubt themselves by day 3

• We need to contact them immediately

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Waiting can be hurting our duration

• Waiting for a call is too late

• Scheduling an appointment with PC only when she is available

• Waiting for lists or reports can be too late

• Sending moms a packet of material

• No protocol exists

• Protocol is “3 contacts in first week”

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92% of mothers report > 1 concern at day 3

• Most predominant difficulty with infant feeding (52%)

• Milk quantity (40%)

• These concerns were significantly associated with discontinuation of breastfeeding

• We can address these concerns with the techniques we have just discussed

– Wagner, 2013, Pediatrics

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Implementation strategies

• Walk in visits and weight checks

• Contacting the hospital to receive notification of delivery

• Allowing PCs to visit moms at hospital

• Using cell phone, Facebook and texts

• Incorporate exclusive breastfeeding

• Mom’s group

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Question 5

• How strong is your focus on first visit after delivery

• Strong 44 responses – Depend on form?

– No protocol?

• Average 24 responses – Ever 2 or 3 days in first week after delivery

• Weak 4 responses – Reach mom within 3 days?

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TODAY: DEVELOP A PROTOCOL FOR CONTACTING NEW MOMS

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Question 6: % of moms that contact you within the first week

• 5% to 90%

• How can we improve this

• Share barriers and successes

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Implementation strategies

• Walk ins

• Allow PCs to visit hospitals

• Face to face contacts

• Building a relationship with the mother

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Question 7

• How often after initial contact do you contact the mom in the first week?

• What can help us to improve this?

• Only when a mom calls with a question

• Average 1 -2 times

– Most common responses

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Implementation strategies

• Evaluate our success in providing support

• Relationship building

• Change practices on when and how mom is contacted after birth

• Texting and Facebook

• Provide support outside of business hours

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Question #8

• Duration rates increased or decreased

• Most said increased

• A few said remained static

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What do YOU think caused the change?

• BF education for staff, lots of it!

• IBCLC services available

• Increased prenatal counseling

• Referrals from local hospitals

• More contacts, PN and PP

• More breastfeeding friendly

• Awareness of BF services at clinic

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What do you think caused the change?

• Peer Counselor

• Strong focus on breastfeeding

• Breastfeeding is the normal way to feed a baby

• Mom support group

• “Increased but there is more work to do”

• What can you implement?

– Develop your plan

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Question #9

• What your agency successfully implemented?

• More frequent follow up of PP

• Paced bottle feeds

• Baby behavior

• Peer support

• Clinic signage

• Staff training

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Question #9

• Breastfeeding group with CHP and PC

• “how is breastfeeding going?”

• Weighing babies, newborn café

• BF contact when asking for formula

• Posters, BF room, BF friendly environment

• Community, hospital out reach

• Texting clients

• Moving PC closer or integrating with clinic

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Question #9

• Moved/changed support group

• PC brings baby to work

• Laid back breastfeeding incorporated

• Hospital visits

• Bf in service for staff

• More frequent contacts

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Question #10

• Idea not successful

• Poor attendance at support group

• “go to place for breastfeeding”

• Walk in BF appointments

• Time constraints for frequent contacts, referral when requesting formula

• Developing a report for early contact

• Laid back breastfeeding “staff buy in”

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Question #10

• Hospital refusal to change

• Bf classes/education

• Reaching out to physician offices

• Facebook

• Contacting moms soon after delivery

• Providing pumps

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Question #10

“we have not implemented initiatives that were not successful. Salary, Staffing and funding have been the greatest barrier over all.”

“I feel any initiative we have put to work has contributed to increased success”

“I cannot think of one that we felt were not successful”

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WHERE ELSE CAN WE GO?

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NWA Six Steps to Achieve

Breastfeeding Goals for WIC

Clinics

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1. Present exclusive breastfeeding as the norm for all mothers and babies

2. Provide an appropriate breastfeeding-friendly environment

3. Ensure access to competently trained breastfeeding staff at each WIC clinic site

NWA Six Steps to Achieve Breastfeeding Goals for WIC Clinics

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4. Develop procedures to accommodate breastfeeding mothers and babies

5. Mentor and train all staff to become competent breastfeeding advocates and/or counselors

6. Support exclusive breastfeeding through assessment, evaluation, and assistance

NWA Six Steps to Achieve Breastfeeding Goals for WIC Clinics

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WHAT DO THESE MEAN?

And do we achieve this?

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SIX STEPS TO ACHIEVE BREASTFEEDING GOALS CHECKLIST

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Step 1

• Educate PN moms at first visit

• Bf is the norm

• Discuss benefits of exclusive Bf food package

• Ask how is breastfeeding going?

• LA BF Coordinator attend coalition meetings in community

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Step 2

• Posters, pictures of BF mothers

• Ensure that printed materials adhere to the WHO Code

• Participants encouraged to Bf in waiting room

• BF classes offered

• Formula education materials kept out of view

• A private Bf area

• Staff is supported in Bf needs, flexibility

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Step 2 continued

• Supplies provided following assessment by trained staff

• What supplies do you use?

• How do you assess for the need for them?

• What are the requirements for training of staff?

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Step 3

• Breastfeeding staff is available during clinic hours

• Access to IBCLC

– How can you do this?

– What staff has received training per NSS

• Warm line available?

• PC available after hours?

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Step 4

• Flexible scheduling to accommodate BF mothers with problems

• Lactation staff available at walk ins, by phone, by appointments

• Collaboration with community partners

• Referral network

– How do you find the information?

– What information is available for moms?

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Step 5

• Staff completes BF orientation

• Bf training

– What are we doing about this?

• Staff participates in BF training and continuing education

• Staff is supported to obtain IBCLC

• Staff mentors each other

• Adequate clinic time for “hands on”

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Step 6

• IBCLC is available for referral and mentorship

• PC services are incorporated into clinic

• PC services are available at each site

• Staff is equipped with skills to evaluate, assist and refer participants

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Why PC services?

• Effective method to support BF

• Women want mother to mother support

• Women want someone who has been ‘in their shoes”

• Loving Support definition

– BF own infant for 1 year

– Participated in WIC services

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Reasons why moms discontinue BF

• Work or school

• Not enough milk

• Soreness

• Doctor recommendation

• Did/would not latch

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How PCs can help

• Contact with moms – Phone – In person – hospital

• Provide correct information • Provide support to continue • When moms had support of PC they were less

likely to stop due to challenges or not enough milk – JHL, September 5, 2014

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Barriers to PC program

• Fluctuating funding

– Enough funding

• Finding the right person

• Flexibility of hours, schedules

• Incorporating the program into an existing WIC agenda

• Training

• These are the passionate women

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How can we encourage them?

• Support from WIC staff

• Better communication with hospital

• Social media is necessary

• More hours

• Training opportunities

– Baby behavior

– Problems, when and how to refer

– Shadow an IBCLC

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PCs can support our efforts

• But we need to support them

• Inclusion

• Education

• Tiered career path

• Hospital contacts

– How are we approaching this?

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EARLY POSTPARTUM CONTACT IS ESSENTIAL

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92% of mothers report > 1 concern at day 3

• Most predominant difficulty with infant feeding (52%)

• Milk quantity (40%)

• These concerns were significantly associated with discontinuation of breastfeeding

• We can address these concerns with the techniques we have just discussed

– Wagner, 2013, Pediatrics

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Breastfeeding barriers

• First few days postpartum

• Not enough milk 37%

• Latch 29%

• Hospital staff 25%

• Separation from baby 31%

– Teich, 2014

• We can resolve all of these with support and laid back breastfeeding

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How do we approach these concerns?

• PN education

– Feeding cues

– Skin to skin

– Laid back breastfeeding

• PP early contact

• PC contact, follow

• Weight checks

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4 new articles in January 2014

• Might give us some ideas

• Help us find a new path

• Enhance what we are doing well

• Improve ideas we have done for awhile

• Bring fresh ideas to our plans

• And to our everyday interactions with moms

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Articles for reference

• Still nursing at 6 months: a survey of breastfeeding mothers

– Augustin, Donovan, Lozano, Massucci, Wohlgemuth, Jan 2014. MCN,39(1):50-55

• Effect of primary care intervention on breastfeeding duration and intensity

– Bonuck, Stuebe, Barnett, Labbok, Fletcher, Bernstein. Jan 2014. Am J of Public Health 104(S1):S119-127

• WIC Peer Counselor contact with first time breastfeeding mothers

– Campbell, Wan, Speck, Hartig. Jan 2014. Public Health Nursing. 31(1):3-9

• Women’s perceptions of breastfeeding barriers in early postpartum period; a qualitative analysis nested in two randomized controlled trials

– Teich, Barnett, Bonuck. Jan 2014. Breastfeeding Medicine. 9(1): 9-15

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First, what is the problem?

• Many women discontinue within the first week to ten days

• Come into the clinic requesting formula

• Mothers are overwhelmed

• Being a new mom is not quite what they thought it would be

• Exhausted, tired

• Just do not know what to do and formula seems easier

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Some supplement in the hospital

• Due to inadequate preparation

– Baby behavior, waking, sleeping, crying

• Lack of preparation

– no milk, not enough milk, baby “starving”

• Formula as a solution to their problems

– Formula seems easy

– Offered easily

– Baby appears to respond to formula

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DISCUSSION: HOW CAN WE ADDRESS THESE CONCERNS?

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PC interventions

• Prepare the mom for the hospital experience

• Prepare the mom for first few days of breastfeeding

• Discuss her support system

• Include and educate her support people

• You can help her anticipate problems

• Manage them if they arise

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What works?

• PCs are the major source of breastfeeding information

• Contacts early in pregnancy

– It is never too early

– Talk to everyone

• Contact at delivery

– How can you achieve this?

• Contact in first 2 days after discharge

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What works?

• Combination of breastfeeding support and education

• Intervention during pregnancy and immediate postpartum

• Increase availability of PC

– How can you get the most out of the time you have?

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Interventions that increase duration

• Scheduled, on going visits integrated into routine care

• Interventions during pregnancy

• Intervention and follow up during the early post partum

• Follow up through out breastfeeding

• Not JUST when there is a problem

– Mom may not report the problem

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Prenatal interventions

• Talk to moms at the first visit

• Get her name and follow up right after first visit

• What has she heard about breastfeeding?

• How does she feel about breastfeeding?

• Request every mom attend a feeding class

• Meet her at her next WIC appointment

– Face to face encounters work

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Combined intervention

• Meaning PC and CHP, affected sustained breastfeeding more than initiation

• Increased exclusive breastfeeding

• 30% reduced risk of weaning through 6 months

• How can we work with the CPAs to make breastfeeding more of a team effort in our program?

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Another combined effort

• Working with health care providers

• How can we improve our relationship with them?

• What would help the moms the most?

• What about efforts with work places?

– 22% saw work or school as a barrier

– Provide information on pumping at work

– Make breastfeeding work for HER

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Survey of over 400 mothers

• 60% still breastfeeding at 6 months

• What breastfeeding practices were identified with this long term continuation group?

• What happened at the beginning (birth) supported continuation

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Breastfeeding practices

• Skin to skin within the first hour

– 62% of those breastfeeding for 6 months did skin to skin in first hour

– These mothers also have a higher rate of breastfeeding in the first 2 hours

– Positive message from the very beginning

– They know they can do it!

– How are you educating moms about skin to skin?

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Breastfeeding practices

• Support of father

– 85% of those still breastfeeding

• Support of family and friends

– 74% report their family or friends were positive about the benefits of breastfeeding

How can we more effective in helping support people?

Include support people

Provide support people with specific tasks at birth and

days at home

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Breastfeeding practices

• Education

– More likely to have breastfed previously

– More likely have taken a class prenatally

• How can get more moms to class?

– More likely to have seen an LC after going home

• How can we increase our post partum follow up?

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Breastfeeding in public

• Breastfeeding in public

– 67% supported breastfeeding in public if the mother was discreet

– 32% said okay any time

• This is an important prenatal issue to address

• Have this conversation early

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Breastfeeding practices

• Formula use more likely if first baby, cesarean birth, not performing skin to skin in first hour, and more than 2 hours before initiating breastfeeding for the first time

• Using formula in the hospital significantly decreased the rate of mothers breastfeeding at 6 months

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Reasons for formula use

• Baby seemed hungry

• Jaundice

• Baby lost weight

• Low blood sugar

• Help with latch!!!!

• Premature in NICU

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When do we address formula use?

• Prenatally – Discuss how formula interferes with breastfeeding

• Just before delivery – Reminder she does not need that “just in case

bag”

• First follow up call after delivery – How is breastfeeding going?

– Why not use formula

– Take milk to make milk

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Reason for discontinuing breastfeeding

• Low milk supply 34%

– Still the number one reason

– Work on her confidence

– Remind her that supplements decrease supply

• Baby did not latch on 27%

• Returned to work 26%

• Baby seemed hungry or not satisfied 23%

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So what can we do?

• Teach skin to skin

• Encourage mothers to do this, explain benefits

• Discuss with support people

• Talk to hospital about care provided and offered to mothers.

• Why does WIC encourage our mothers to do this

• Skin to skin is free and easy!

• And it works

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Talk with moms about

• Stress of being a new mom

• PCs are perfect in this role

• This can help them to know it happens to everyone

• Talking to you WILL help

• Moms need to know this stress/adjustment is not about breastfeeding

• This is about being a new mom

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Exhaustion

• Happens to everyone

• Giving a bottle is not a solution

• Discuss the reality of bottle feeding

• Someone may offer to help you now but what happens later? Week? Month?

• Breastfeeding moms get more sleep!

• Is it really easier?

– NO

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What can we do?

• Improve consistency within staff – Everyone needs to work together, say the same thing

• Provide more education for mothers • Postpartum information and support groups • Include support people

– Why is this important for mom and baby – They make the difference – What is their role?

• Have support available for post partum concerns – but reach out before there is a problem

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Follow up after delivery is essential

• This is when moms are most likely to quit or supplement

• They need you now

• If you text her, you may get a response like “yes I had my baby”

• Or not yet, but easier than the phone call

• Just ask “How are you doing?”

• Indicates concern without pressure

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Talk to moms about reality in the hospital

• This is when they are so tempted to supplement or give up all together

• They are afraid for their baby

• They do not understand newborn behavior

• Interpretation of newborn behavior is usually negative

• Breastfeeding is not working!

• Look at this……..

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What can we do?

• Working moms

• Education on pumping and expressing milk

• Human milk is less fragile than formula

• How to do it, how to accomplish it

• How to keep breastfeeding going

• Why it is important for the baby

• How it is easier for the mom

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Suzanne Colson’s research

• Showed us that mothers give up when they are not comfortable

• Teach them comfort

• What will work for them

• They do not need to look like the pictures

• Prepare support people, nurses

• This I different

• They need to be comfortable

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We have been doing many of these things already

• We need to intensify our message

• We need to encourage all of our moms

• Duration and exclusivity are our goals for this year

• How do we complete computer forms?

• Did the mother ever breastfeed?

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Moms need this reality check

• Message:

• My baby is crying. He is hungry. I can’t do this.

• Reality:

• Crying is the baby’s language. What else is happening?

– Too warm, cold

– Need to be held or rocked

– Soothing techniques

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What about going back to work?

• Mom’s barriers

• Time

• Support

• Place/time to pump

• Is it worth it?

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New videos available

• How can we use them to help our mothers?

• For employees

• For employers

• For vendors

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BABY BEHAVIOR

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Why is this important for moms

• 4 out of 10 infants born in the US do not form a strong bond with either parent

• And they will pay for that the rest of their lives

• 40% of infants live in fear or distrust of parent

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Why this is important

• This will translate into aggressiveness, defiance and hyperactivity

• Parents do not respond to their needs

• When a parent picks up a child when they cry, holding and reassuring them, the child feels secure

• Research from Princeton University 3/27/14

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Strong attachment

• Supports social & emotional development

• Strengthens cognitive development

• Children are more resilient to poverty, family instability, parental stress and depression

• Better language development

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Targeted interventions

• Highly effective in helping parents

• To learn proper expectations of infants

• Foster secure attachment

• Parents need more support to provide proper parenting education

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Why this is important

• Nearly 1/3 of US parents do not know what to expect from their newborns

• How to help them grow, and learn

• Parents often misinterpret behavior

• Less likely to have interactions with infants

– University of Rochester, 2008

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Babies have so much to tell us

• From the very beginning

• They are born with neonatal reflexes to get to the breast

• They are born to breastfeed!

• Parents who understand baby behaviors will breastfeed longer

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Primitive neonatal reflexes

• Hand to mouth

• Mouth gape

• Tongue dart

• Hand/finger flex and grasp

• Arm/leg cycle

• Head lift

• Head bob

• Suck and swallow

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From the very beginning

• Babies are communicating with us

• They are driven to connect

• Our goal is to help parents understand these messages and help them to feel confident in their response

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All infants need the following to develop

• Shelter/environment

• Food

• Touch

• Interaction

• Response to needs

• All of these are necessary for brain development

• Information in child development literature

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One word about crying

• Babies whose parents responded to quickly to their cries were less likely to cry in the second year of life and were more advanced in communicative competence

– Bell and Ainsworth, 1972

• Babies learn the power of communication and advance to more sophisticated methods

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SO HOW DO WE HELP MOTHERS?

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Being a new parent is stressful

• New parents cope with stress by either trying to fix the problem when we believe there is a solution

• Or if we do not believe there is a solution, we cope by trying to calm ourselves

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A frustrated new mother

• Will ask for help if there is a solution

• If she does not think anyone can help her, she will either ignore it

• Or she will do whatever she can to keep her baby from crying

• Her usual tool is OVERFEEDING

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Help our staff to learn how

• To help mothers

• Wouldn’t it have helped you to think about what your baby is thinking

• We react rather than respond

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Research has shown

• Knowledge about the transition to parenthood is poor

• Parents rarely understand baby cues or language

• They frustrated by not knowing what the baby wants or needs

• Need more information on the elements of baby care and life changing events.

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Help parents to understand their babies

• www.secretsofbabybehavior.com

• Teach engagement with their babies

• Encourage parents to explore their baby

• This encourages them to learn cues and how to respond

• Encourage them to learn how to care for their baby

• Sanders, 2006

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Paradigm shift

• We have always looked at infant care from OUR perspective

• We need to think about it from the baby’s perspective

• Parents need to know what is best for the baby

• This is a huge change in their lives

• They are overwhelmed and unsure

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Engagement

• I want to be near you

• I want to connect with you, learn from you

• Or

• I need things to be different for me

• Let me be

• What would happen if we tried to feed baby now?

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Babies do tell you they want to engage

• “I want to be near you”

• Intently staring

• Feeding sounds

• Rooting

• Babies driven to connect

• Sometimes they cry to get your attention

– May indicate their need to be stimulated, comforted

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What do parents need to do?

• Look at what their baby is doing

• Recognize what their baby is telling them

• Respond to baby’s request

• We can help parents to learn how to respond

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However, most parents think

• Any crying or fussing is about food

• Or else hear, let the baby cry it out, “you will spoil him”

• If they misinterpret baby’s message

• What will happen?

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Why Do Babies Cry?

• Crying is a means of communication • There is something wrong either with me or my

environment – It signals a need

• Food • Comfort • Warmth • Mother’s presence • Pain • Illness • Fear

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Necessary for them to address infant hunger

• Do not see these normal baby behaviors as need

• They see all behaviors as indication of hunger

• And they do not understand how to fix this problem

–Quiet them, good mother

– If feed them, good mother

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Crying is the baby’s Super Power

• Crying drives adult activity

• We will do SOMETHING

• Crying needs to be stressful to motivate us to care for the baby

• Not about manipulation or spoiling

• Babies are helpless immature beings with feelings and instinctual cries for survival and social imprinting. Palmer, Baby Bond 2009

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Variety in ways to soothe a crying baby

• Different positions

• Touch

• Holding

• Words to waken or soothe

• Repetition to soothe, address needs

• Food is not always the answer, just the quick one

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What Is Baby’s ‘Second Night’?

• Occurs about 24 hours after birth (generally the second night)

• Baby wants to be on the breast seemingly constantly – Often from 9 pm to 1 am

• Falls asleep at breast – wakes as soon as put down

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That Second Night…

• Mom is exhausted – Generally adrenalin is depleted

from the excitement of the birth

– Hasn’t had much sleep

• Is concerned that baby is “starving” and that she “doesn’t have anything” – Often staff reinforces that message

thru offering supplements and to take the baby back to the nursery

112

What Is Really Going On?

• Baby ‘wakes up’ that second day – In the hospital setting is bombarded with

new sensory input – Difficult to organize himself – Needing what is familiar (womb) to

reorganize – Closest to womb is the breast which

provides much of the same sounds as in prenatal life

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What Can We Do?

• Helpful to warn moms about 2nd Night

– Give her a handout

• “Baby’s Second Night” – from LEC

• Reassurance this is normal and it isn’t because she is “starving” her baby

• Teach her how to deal with it….

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Second night at home?

• Can happen anytime the baby is over stimulated

• Doctor visit

• Visitors

• Busy day

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Infant feeding cues

• Important information for new parents

• Gives parents the confidence to continue

• All parents need this information

• Builds attachment with the baby

• Many new parents have limited experience with babies

• Parents are separated from their babies

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Biggest concerns

• Feeding

• Hands near mouth

• Sucking sounds

• Rooting

• Crying

• Fussing

• Tired/yawning

• Stiffen and tighten

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Biggest concerns

• Sleep

• Babies spend more time in light sleep

• Fall asleep faster

• Wake easier

• Sleep through the night

• Prior to cry

• Stiffen

• Pull or push away

• Yawn or frown

• Tighten face or muscles

118

Most common concern from parents is about their infants sleep

• Parents have unrealistic expectations of their infants sleep

• Lack of sleep drives them to do things they never thought they would do

119

Parents expect a schedule

• That babies cannot deliver because they have not developed the ability to do this yet

• Babies are supposed to sleep the same as adults?

• But they do not for very good reasons

120

Sleep patterns • Infants

– Period of REM sleep first • Adults begin in a deeper sleep pattern

– Spend 50% of time in REM sleep • Adults only about 20%

– At 3 to 5 months spend about 40% in REM – 6 to 24 months about 30% – REM sleep essential for brain development and maturation

• Born with 25% of brain size – Easily awakened from REM

121

In the Beginning • Sleep patterns are very unpredictable

• As they mature they fall into the light/dark patterns based on circadian rhythms

• In the first three months these rhythms are not well established

• Days and nights are confused

• They have always been in the dark until now!

122

Three reasons why babies do not sleep through the night

• Reason One: they wake to eat

–Rapid growth requires frequent feeds

–Small stomach capacity

–Need the response and closeness of caregivers to develop

• M. Jane Heinig

123

Reason Two

• Babies fall asleep dreaming – REM sleep

• Then move to deeper sleep

• Exact opposite of adults

• Dreaming is vital for their brain development – Blood flows to brain while dreaming

– Encourages neural connections

– Premature infants dream even longer than term

– About first 30 minutes

124

More likely to wake during

• Dream or REM sleep

• Noise may wake them

• Parents will see eyelids flutter and may see twitching

– Easy to visualize

• Hold your infant until he/she goes into deep sleep

• Helps them to stay asleep

125

Reason Three

• Wake to be comfortable and feel safe

• As their body matures, they may be hot or cold or need to move or breathe more deeply

• This development usually begins to smooth out after about 6 weeks

• Reach neuro behavioral organizational ability

• Is this related to synchrony with mother’s sleep?

126

Lots of ideas

• What can you do next week?

• What can you do within a year?

• Meeting with administrators

– What are the barriers?

– Why so few?

127

MAKING CHANGE IN OUR CLINICS

128

What we think will work

• Behavior will change if we give people information

• Then they will do the right thing

• Healthy food versus junk food

129

What will people accept change

• The dilemma

• Is it worth it?

• Can I do it?

130

Motivation and ability

• Make the undesirable- desirable

• Grab peer pressure

• Design rewards and demand accountability

• Surpass your limits

• Find strength in numbers

• Change the environment

131

Make the undesirable - desirable

• Try it immerse people in the activity

• Focus on a sense of accomplishment

• Connect the behavior to the mother’s sense of values

• Help moms who are resistant discover links between breastfeeding an their own values

– What are her goals?

– What is important to her?

132

Behaviors leading to breastfeeding

Breastfeeding

Connection with baby

Broadened understanding

Growth of passion

Fear of formula

Obsessive passion, narrowed understanding

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Can I do this?

• Devote attention to clear, specific and repeatable actions

• Insist on feedback

• Break tasks into specific actions

• Build in recovery strategies, tell stories about setbacks

• Regain emotional control

• Surpass you limits

134

Grab peer pressure

• Respected and connected people can exert influence

• Make it safe to talk about myths and concerns

• Create a new social network to support the new behavior

• Motivation = Grab peer pressure

135

Structural motivation

• Use incentives and disincentives wisely

• Celebrate small wins

• Make sure rewards are linked to behavior not outcomes

• Consider small heartfelt tokens of appreciation

• Use punishment sparingly

• Motivation- design rewards and demand accountability

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Structural ability

• Clues from the environment profoundly influence the behavior

• Make the invisible, visible

• Create opportunities for informal contact and communication

• Make the behavior unavoidable

• Ability: change the environment

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Integrating care

• We need to see and look at the dyad

• Not just the mom

• Not just the baby

• But the two of them together

• The mother/baby is a person, organ system

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Reminder: Motivation and ability

• Make the undesirable- desirable

• Grab peer pressure

• Design rewards and demand accountability

• Surpass your limits

• Find strength in numbers

• Change the environment

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We need at least 4

• Behaviors to make a change

• Look at all of them

• Which can you use to motivate this mother?

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Determine Vital Behaviors

• http://www.youtube.com/results?search_query=four+sources+of+influence+

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What does this mean to us?

• Speak carefully

• Speak less, listen more

• Provide anticipatory guidance

• Follow up closely

• Emphasize the value of nurturing

• Harness peer influence

• Build an environment that welcomes breastfeeding

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GO FORTH AND DO GREAT THINGS

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