Women’s Health Today

Since 1976, Chris Auer has assisted mother-baby pairs, particularly those within a high risk demographic. Here she recounts a sad reason for 10 minutes of fame and implicates the health care system and its complex relationship with the insurance industry for failing these families.

What precipitated my brief minutes of fame was a cluster of tragedies. Once these cases were reported, the Prime Time Live crew, two camera men and a journalist taking Diane Sawyer’s place, arrived at our hospital in 1998. The camera crew rounded with me in patient rooms, as I talked to mothers all afternoon. As we walked down the hall, I recall the men admiringly commenting to each other when they saw a framed certificate signed by Hugh Downs, on behalf of the U.S. committee for UNICEF, where he served as Chairman of the Board. (Ironically, Mr. Downs was from my hometown of Akron, Ohio.) The certificate he had signed affirmed our hospital’s intent to seek the designation of a Baby-Friendly Hospital. The requirements for the designation assured that a hospital is complying with best-known practices to support breastfeeding. One of those practices includes assuring that breastfed babies have early, appropriate follow-up care. Dr. Ballard ordered two visits by home care nurses prior to the pediatrician visit. I attribute this decision to assuring our breastfed babies were protected.

Mothers held their babies close as we discussed how their breastfeeding experience was going and what to expect in the early days at home. Following this, the crew recorded an interview between the journalist and me.

Five babies, 5 to 14 days old (average 10 days old), had been admitted to the local Children’s Hospital over a 5-month period for treatment for dehydration and other sequela. Ten percent is usually the upper acceptable limit of weight loss in the first days of life. The average weight loss for these babies upon readmission was 23 percent. It was frightening to hear each of their stories from their neonatal nutritionist. At that time, their hospital had no lactation department. The nutritionist and several of the doctors turned to me for insight into how these tragedies could have happened. With each call, the stories began to unfold with eerie similarity: older (age 28 to 38), first-time mothers, relatively short hospital stays (average for the four vaginal deliveries, 33 hours, for the one cesarean-section, 48 hours), no pediatric visit after discharge, infrequent breastfeeding, weak suck, and each mother, college-educated.

Without conducting in-depth, interviews myself, it was impossible to understand exactly what had gone wrong with each particular case. We agreed that the mothers had been through too much already to be interviewed. What I did know was that upon admission, no mother produced milk when she first pumped at the hospital. Was this because her mature milk, which normally arrives by day 3, had never come in? They each had reported some leaking. Or was it that the stress of her baby’s readmission inhibited the release of the milk, or worse, had dried it up altogether? I’d had a mother once tell me that she only breastfed for 5 months because, upon seeing the baby’s daddy shot dead, she subsequently never made a drop of milk. Stress is powerful.

As I watched the Prime Time segment a few weeks later, I wasn’t surprised that only two of the five mothers consented to be interviewed. As one described watching her newborn wither away on the ambulance drive to the hospital, I thought of how unfair it is to expect a first-time parent to distinguish between a baby who sleeps because he has a full tummy, and one who sleeps because he’s getting inadequate calories and milk. I thought of how tired moms are after delivery and how difficult it is to recall the myriad instructions they are given during their postpartum stay. The interviewer didn’t mention that each new mother had had a short hospital stay. At the time of these births, a new dictate from health insurance companies mandated shorter stays, 24 hours for vaginal births. Many neonatologists felt this was a strong contributing factor to the tragedies. I had done my best to navigate the interview without in any way sounding like I blamed the parents. I did not. Four of the five had taken a prenatal breastfeeding class, mind you. They’d tried their best to prepare. In my estimation, it was a sad systems failure—short hospital stays coupled with delayed follow-up.

I was invited to meetings that senior Children’s Hospital physicians and administrators had with insurance officials from several companies. I was able to provide input on what would best serve the mothers of breastfed babies, both during their hospital stay and after discharge. It took nearly a year, but the meetings led to states requiring that insurance companies cover a hospital stay of up to 48 hours for a routine birth and 96 hours for a cesarean birth. This remains the law of the land. The Academy of Pediatrics (AAP) then revised its guideline for how soon a breastfed infant should be seen by a health care provider. When I had my children 40 years ago, babies were not seen until they were 2-weeks-old. Now, the AAP recommends that babies have a physician or nurse practitioner follow-up visit between day 3 and 5 of life.

None of these five women delivered at our hospital. Fortunately, we had a policy in place that made these types of tragedies less likely. The timing of the two home visits that were ordered contributed to this: one visit at 24 hours post-discharge, the other, 48 hours later. Additionally, in 1995, cut-backs had not yet occurred within the health department, and public health nurses were available to make many of these home visits.

After the Prime Time coverage, positive strides were made along the care-continuum, from prenatal to post-discharge, all over the U.S. One month later I received a letter from Dr. Ted Greiner, a Swedish professor of International Child Health, with his own speculations of why the U.S. health care system was failing to be a safety net for babies. He had great insight into best breastfeeding practices around the world, had studied at New York’s Cornell University, and had conducted some of the most detailed studies of breastfeeding practices in West Africa. His PhD work in nutrition focused on breastfeeding in Yemen. Dr. Greiner’s curriculum vitae also includes work with the World Alliance for Breastfeeding Action, whose focus is to protect, promote, and support breastfeeding. I was hearing from an expert. He insisted that women should be better educated during their pregnancy and be allowed longer hospital stays. He was certain that if more U.S. hospitals followed the Ten Steps to Successful Breastfeeding, as outlined by the World Health Organization, then babies would be discharged with breastfeeding better established.

In the end, one baby’s jaundice was so severe that it crossed into the brain, causing permanent neurologic damage. Two babies had grade III brain bleeds. The consequences of this, only time would tell. One of the babies suffered a stroke. The parents of the fourth baby, born in February, called on a snowy day to cancel a follow-up appointment at the delivering hospital. The father mentioned that his son’s leg seemed a little blue. Days later, this infant’s leg was amputated secondary to an iliac artery thrombosis. The final baby, despite severe weight loss and dehydration, had no apparent other maladies. There was no getting around the fact that this Prime Time segment created so much fear about breastfeeding that the breastfeeding initiation rates in the country dipped for several months. How could it not?

Twenty years later, though infrequent, there are still feeding tragedies. Babies need very close follow-up after discharge and parents need to know when to supplement breastfeeding without any overlay of external or internal pressure, save keeping their little one safe. We’re allies to this end: all parents, all health care providers, the insurance industry, and all lactation consultants. 

Chris Auer is a registered nurse and lactation consultant who has worked at the University of Cincinnati Medical Center for 42 years caring for mother-baby pairs from all walks of life and from as many as 77 countries, particularly those within a high risk demographic and in a Level III NICU setting. For over 20 years, Chris has provided pediatric resident lactation education and internship training and has published articles in seven peer-reviewed journals. Under One Sky is available here.

Read a review of Under One Sky by Doraine Bailey.