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Why Are the Breastfeeding Rates in Rural America So Low?

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In 2011, moms across the country protested Target, staging “nurse-ins” and refusing to shop there after a breastfeeding mother was threatened with legal action for nursing in the women’s clothing section. I was a television reporter in my home state of West Virginia then and covered this story, admittedly and embarrassingly a little skeeved out. I was in my early twenties, and remember wondering why someone would want to breastfeed in public anyway.

Born and raised in Appalachia, I had no exposure to breastfeeding. I wasn’t breastfed, nor were any of my younger family members. There were a lot of babies in the church I went to growing up, but I don’t remember seeing a single mother nurse her child. It wasn’t until I moved away from the mountains of West Virginia that I realized breastfeeding was actually quite common.

Across the country, as many as 82 percent of mothers breastfeed their babies for some amount of time. In rural areas, the numbers are lower, with 68 percent of women starting out breastfeeding. In rural Appalachia, the dichotomy is at its most extreme, with only 57 percent of mothers even attempting to nurse.

Appalachia is comprised of thirteen states, many of which are some of the most economically depressed states in the country and rank near the bottom when it comes to both median household income and breastfeeding rates.

In West Virginia, for example, the median income is $43,000, and less than 35 percent of mothers are breastfeeding by the time their child hits the six month mark.

As someone from Appalachia, I’m as sick as every other Appalachian is of hearing how sad and depressed and poor my beloved home state is. I roll my eyes at lists that rank West Virginia at the bottom, yet again. But you can’t have a conversation about breastfeeding statistics without talking about income. They’re that tied together.

Dr. Susanna Kapourales is a pediatrician in Teays Valley, West Virginia, just a few minutes away from the state capital of Charleston. She grew up in the town of Williamson, where nearly half of the three thousand residents live below the poverty line.

“My mom was the only person in her community who breastfed at all,” Dr. Kapourales said. “She had no support whatsoever; she learned how to breastfeed by a book. She had absolutely no help in the area because nobody breastfed. But she knew that it was better for her babies.”

Kapourales’ mother moved to Williamson as an adult; and for many native West Virginian and other rural Appalachians, the aversion to breastfeeding is deep-rooted.

Though the American Academy of Pediatrics recommends breastfeeding until twelve months, Dr. Kaporales says that most of her patients nurse for about six months and switch to formula. “A lot of people will get to that six months and then either from work restraints with pumping or something else, they just find it easier to use formula.”

The Federal Family Medical Leave Act, which pertains to all fifty states, only applies to employers with at least fifty employees and doesn’t guarantee paid time off. In fact, the United States is still the only developed country that doesn’t offer paid leave for new mothers, something that could really aid in setting good breastfeeding practices into place.

Federal law does also require employers to provide “reasonable daily unpaid breaks” to pump, but the conditions or the culture aren’t always encouraging. If you have an office you can close the door to, it’s a little easier, but what if you work at Red Lobster? Where do you go to pump? For many mothers, pumping at work just isn’t an option.

“Most of the time, they are so exhausted when they get home and they don’t have enough support,” Dr. Kaporales said.

Of course, there are many other factors beside someone’s income that can deter mothers from breastfeeding -- lactation or latching issues, issues with the baby’s weight or even medication the mother needs to take. But perhaps the most profound reason moms don’t nurse, in my experience, is that the act of breastfeeding itself is at odds with cultural norms, leaving them without the support of their family and friends.

Dr. Kaporales said, “some families have been raised to think that it’s weird -- and then others, come hell or high water, do not want to give their babies formula. I see both, and I really think it has to do with their family.”

Cigarette smoking and drug use also play a big part in preventing mothers from breastfeeding.

In West Virginia specifically, 29 percent of residents admit to smoking regularly, and drug use is rampant. At the hospital system Dr. Kapourales works for alone, there are 2,900 births per year -- babies from Ohio, Kentucky and West Virginia. Of those tiny infants, one fifth were exposed to drugs in the womb, and 400 had to be medicated after birth to help combat withdrawal symptoms that leave them screaming and shaking uncontrollably.

In hope to raise the breastfeeding rates across the country, hospitals have adopted a certification system that list them as “baby friendly.” At “baby friendly” hospitals, breastfeeding is encouraged by giving the newborn to the mother right away, foregoing nurseries by leaving the newborn with the mother the entire stay, and providing lactation support before discharge. West Virginia has just one such hospital.

That kind of support, Dr. Kapourales said, is crucial in educating, encouraging and sustaining breastfeeding. It should probably even start during pregnancy.

“In the community, if people don’t have enough support, they get discouraged with it and quit,” she said. “Those first three weeks are hard, and people feel helpless and like they can’t get through it. And if you don’t have that support system to do it, it’s hard.”

But breastfeeding rates won’t rise in these rural areas, Dr. Kapourales said, until breastfeeding is normalized. And the only way to normalize breastfeeding is to do it. In public. All the time. At the grocery store, at your older kids’ soccer practice -- even at Target.

Photography by Belle Savransky for Well Rounded.

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We spend a lot of time prepping for the arrival of a baby. But when it comes to the arrival of our breast milk (and all the massive adjustments that come with it), it's easy to be caught off guard. Stocking up on a few breastfeeding essentials can make the transition to breastfeeding a lot less stressful, which means more time and energy focusing on what's most important: Your recovery and your brand new baby.

Here are the essential breastfeeding tools you'll need, mama:

1. For covering up: A cute nursing cover

First and foremost, please know that all 50 states in the United States have laws that allow women to breastfeed in public. You do not have to cover yourself if you don't want to—and many mamas choose not to—and we are all for it.

That said, if you do anticipate wanting to take a more modest approach to breastfeeding, a nursing cover is a must. You will find an array of styles to choose from, but we love an infinity scarf, like the LK Baby Infinity Nursing Scarf Nursing Cover. You'll be able to wear the nursing cover instead of stuffing it in your already brimming diaper bag—and it's nice to have it right there when the baby is ready to eat.

Also, in the inevitable event that your baby spits-up on you or you leak some milk through your shirt, having a quick and stylish way to cover up is a total #momwin.

2. For getting comfortable: A cozy glider

Having a comfy spot to nurse can make a huge difference. Bonus points if that comfy place totally brings a room together, like the Delta Children Paris Upholstered Glider!

Get your cozy space ready to go, and when your baby is here, you can retreat from the world and just nurse, bond, and love.

3. For unmatched support: A wire-free nursing bra

It may take trying on several brands to find the perfect match, but finding a nursing bra that you love is 100% worth the effort. Your breasts will be changing and working in ways that are hard to imagine. An excellent supportive bra will make this so much more comfortable.

It is crucial to choose a wireless bra for the first weeks of nursing since underwire can increase the risk of clogged ducts (ouch).The Playtex Maternity Shaping Foam Wirefree Nursing Bra is an awesome pick for this reason, and because it is designed to flex and fit your breasts as they go through all those changes.

4. For maximum hydration: A large reusable water bottle

Nothing can prepare you for the intense thirst that hits when breastfeeding. Quench that thirst (and help keep your milk supply up in the process) by always having a water bottle with a straw nearby, like this Exquis Large Outdoor Water Bottle.

5. For feeding convenience: A supportive nursing tank

Experts recommend that during the first weeks of your baby's life, you breastfeed on-demand, meaning that any time your tiny boss demands milk, you feed them. This will help establish your milk supply and get everything off to a good start.

What does this mean for your life? You will be breastfeeding A LOT. Nursing tanks, like the Loving Moments by Leading Lady, make this so much easier. They have built-in support to keep you comfy, and you can totally wear them around the house, or even out and about. When your baby wants to eat, you'll be able to quickly "pop out" a breast and feed them.

6. For pain prevention: A quality nipple ointment

Breastfeeding shouldn't hurt, but the truth is those first days can be uncomfortable. Your nipples will likely feel raw as they adjust to their new job. This will get better! But until it does, nipple ointment is amazing.

My favorite is the Earth Mama Organic Nipple Butter. We love that it's organic, and it is oh-so-soothing on your hard-at-work nipples.

Psst: If it actually hurts when your baby latches on, something may be up, so call your provider or a lactation consultant for help.

7. For uncomfortable moments: A dual breast therapy pack

As your breasts adjust to their new role, you may experience a few discomforts—applying warmth or cold can help make them feel so much better. The Lansinoh TheraPearl 3-in-1 Breast Therapy Pack is awesome because you can microwave the pads or put them in the freezer, giving you a lot of options when your breasts need some TLC.

Again, if you have any concerns about something being wrong (pain, a bump that may be red or hot, fever, or anything else), call a professional right away.

8. For inevitable leaks: An absorbing breast pad

In today's episode of, "Oh come on, really?" you are going to leak breastmilk. Now, this is entirely natural and you are certainly not required to do anything about this. Still, many moms choose to wear breast pads in their bras to avoid leaking through to their shirts.

You can go the convenient and disposable route with Lansinoh Disposable Stay Dry Nursing Pads, or for a more environmentally friendly option, you can choose washable pads, like these Organic Bamboo Nursing Breast Pads.

9. For flexibility: A breast pump

Many women find that a breast pump becomes one of their most essential mom-tools. The ability to provide breast milk when you are away from your baby (and relieve uncomfortable engorged breasts) will add so much flexibility into your new-mom life.

For quick trips out and super-easy in-your-bag transport, opt for a manual pump like the Lansinoh Manual Breast Pump .

If you will be away from your baby for longer periods of time (traveling or working outside the home, for example) an electric pump is your most efficient bet. The Medela Pump In Style Advanced Double Electric Breast Pump is a classic go-to that will absolutely get the job done, and then some.

10. For quality storage: Breast milk bags

Once you pump your liquid gold, aka breast milk, you'll need a place to store it. The Kiinde Twist Pouches allow you to pump directly into the bags which means one less step (and way less to clean).

11. For keeping cool: A freezer bag

Transport your pumped milk back home to your baby safely in a cooler like the Mommy Knows Best Breast Milk Baby Bottle Cooler Bag. Remember to put the milk in a fridge or freezer as soon as you can to optimize how long it stays usable for.

12. For continued nourishment: Bottles

Nothing beats the peace of mind you get when you know that your baby is being well-taken of care—and well fed—until you can be together again. The Philips Avent Natural Baby Bottle Newborn Starter Gift Set is a fan favorite (mama and baby fans alike).

This article is sponsored by Walmart. Thank you for supporting the brands that support Motherly and mamas.

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Motherly is committed to covering all relevant presidential candidate plans as we approach the 2020 election. We are making efforts to get information from all candidates. Motherly does not endorse any political party or candidate. We stand with and for mothers and advocate for solutions that will reduce maternal stress and benefit women, families and the country.

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A viral video about car seat safety has parents everywhere cracking up and humming Sir-Mix-A-Lot.

"I like safe kids and I cannot lie," raps Norman Regional Health System pediatric hospitalist Dr. Kate Cook (after prefacing her music video with an apology to her children."I'm a doctor tryin' warn you that recs have changed," she continues.

Dr. Cook's rap video is all about the importance of keeping babies facing backward. It's aptly called "Babies Face Back," and uses humor and parody to drive home car seat recommendations from the American Academy of Pediatrics (AAP).

"Switching from rear-facing to forward-facing is a milestone many parents can't wait to reach," Dr. Cook said in a news release about her hilarious video. "But this is one area where you want to delay the transition as long as possible because each one actually reduces the protection to the child."

Last summer the AAP updated its official stance on car seat safety to be more in line with what so many parents were already doing and recommended that kids stay rear-facing for as long as possible. But with so many things to keep track of in life, it is understandable that some parents still don't know about the change. Dr. Cook wants to change that with some cringe-worthy rapping.

The AAP recommends:

  • Babies and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat.
  • Once they are facing forward, children should use a forward-facing car safety seat with a harness for as long as possible. Many seats are good up to 65 pounds.
  • When children outgrow their car seat they should use a belt-positioning booster seat until the vehicle's lap and shoulder seat belt fits properly, between 8 and 12 years old.

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[Editor's note: Motherly is committed to covering all relevant presidential candidate plans as we approach the 2020 election. We are making efforts to get information from all candidates. Motherly does not endorse any political party or candidate. We stand with and for mothers and advocate for solutions that will reduce maternal stress and benefit women, families and the country.]

Suicide rates for girls and women in the United States have increased 50% since 2000, according to the CDC and new research indicates a growing number of pregnant and postpartum women are dying by suicide and overdose. Suicide rates for boys and men are up, too.

It's clear there is a mental health crisis in America and it is robbing children of their mothers and mothers of their children.

Medical professionals urge people to get help early, but sometimes getting help is not so simple. For many Americans, the life preserver that is mental health care is out of reach when they are drowning.

Democratic presidential candidate Pete Buttigieg just released a plan he hopes could change that and says the neglect of mental health in the United States must end. "Our plan breaks down the barriers around mental health and builds up a sense of belonging that will help millions of suffering Americans heal," says Buttigieg.

He thinks he can "prevent 1 million deaths of despair by 2028" by giving Americans more access to mental health and addictions services.

In a country where giving birth can put a mother in debt, it's not surprising that while as many as 1 in 5 new moms suffers from perinatal mood and anxiety disorders, more than half of new moms who need mental health treatment don't get it. Stigma, childcare and of course costs are factors in why women aren't seeking help when they are struggling.

Buttigieg's plan is interesting because it could remove some of these barriers. He wants to make mental health care more affordable by ensuring everyone has comprehensive coverage for mental health care and by ensuring that everyone can access a free yearly mental health check-up.

That could make getting help more affordable for some moms, and by increasing reimbursement rates for mental health care delivered through telehealth, this plan could help moms get face time with a medical professional without having to deal with finding childcare first.

Estimates from new research suggest that in some parts of America as many as 14% or 30% of maternal deaths are caused by addiction or suicide. Buttigieg's plan aims to reduce those estimates by fighting the addiction and opioid crisis and increasing access to mental health services in underserved communities and for people of color. He also wants to reduce the stigma and increase support for the next generation by requiring "every school across the country to teach Mental Health First Aid courses."

These are lofty goals with a lofty price tag. It would cost about $300 billion to do what Buttigieg sets out in his plan and the specifics of how the plan would be funded aren't yet known. Neither is how voters will react to this 18-page plan and whether it will help Buttigieg stand out in a crowded field of Democratic candidates.

What we do know is that right now, America is talking about mental health and whether or not that benefits Buttigieg's campaign it will certainly benefit America.

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[Editor's Note: Welcome to It's Science, a Motherly column focusing on evidence-based explanations for the important moments, milestones, and phenomena of motherhood. Because it's not just you—#itsscience.]

If you breastfeed, you know just how magical (and trying) it is, but it has numerous benefits for mama and baby. It is known to reduce the likelihood of developing cardiovascular disease, type 2 diabetes, and rheumatoid arthritis, and cuts the risk of sudden infant death syndrome (SIDS) by half.

If this wasn't powerful enough, scientists have discovered that babies who are fed breast milk have a stomach pH that promotes the formation of HAMLET (Human Alpha-lactalbumin Made Lethal to Tumor cells). HAMLET was discovered by chance when researchers were studying the antibacterial properties of breast milk. This is a combination of proteins and lipids found in breast milk that can work together to kill cancer cells, causing them to pull away from healthy cells, shrink and die, leaving the healthy cells unaffected.

According to researchers at Lund University in Sweden, this mechanism may contribute to the protective effect breast milk has against pediatric tumors and leukemia, which accounts for about 30% of all childhood cancer. Other researchers analyzed 18 different studies, finding that "14% to 19% of all childhood leukemia cases may be prevented by breastfeeding for six months or more."

And recently, doctors in Sweden collaborated with scientists in Prague to find yet another amazing benefit to breast milk. Their research demonstrated that a certain milk sugar called Alpha1H, found only in breast milk, helps in the production of lactose and can transform into a different form that helps break up tumors into microscopic fragments in the body.

Patients who were given a drug based on this milk sugar, rather than a placebo, passed whole tumor fragments in their urine. And there is more laboratory evidence to support that the drug can kill more than 40 different types of cancer cells in animal trials, including brain tumors and colon cancer. These results are inspiring scientists to continue to explore HAMLET as a novel approach to tumor therapy and make Alpha1H available to cancer patients.

Bottom line: If you choose to breastfeed, the breast milk your baby gets from your hard work can be worth every drop of effort.

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