“Even when the risk is quantifiable, it's just not part of the equation”

Chatting about sleep protection, breastfeeding, and mom v baby risk:risk analysis with Dr. Devika Bhushan

A “good mother” should always choose the nutritional option that is “healthiest” for her kid. Right?

What if the “healthiest” option puts her health at risk? What if the “healthiest” option requires quotation marks around that word because it does not have a clear definition for what makes it the absolute “healthiest” option?

What if the “healthiest” option depends on her body?

When there is a perceived level of risk on both sides of a mom:baby risk:risk equation – e.g. the risk of choosing a less healthy option for a baby versus risk of stress exposure for the mother’s body and brain – how can we properly weigh the risk:risk in a way that includes impact on short- and long-term maternal health outcomes?

The ignored health risk of motherhood

Sleep, breastfeeding, and the “good mother” narrative collide with fascinating overlap that (in my opinion) perfectly highlights the ways society over-prioritizes babies/children at the expense of a mother’s health under a false pretense of her choice.

After talking with

Dr Devika Bhushan

about her personal experience with sleep protection and breastfeeding, I knew I had to dig in further with her on all things risk:risk, maternal health, and motherhood narrative.

Devika brilliantly weaves her own journey alongside her expertise as a pediatrician, public health leader (former acting California Surgeon General), and mental health activist. She is a powerhouse and you can find more of her writing HERE.

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Below is an edited transcript. To hear us discuss all the extra bits, check out the recording:

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MOLLY:

After we spoke for the sleep post, I started digesting our conversation along with your other writing.

The sleep prescription

My brain keeps coming back to the risk : risk analysis of all things mom : baby in terms of how we outweigh any potential risk for the baby while disregarding real risks to the mother. Especially when the risk to mom comes from the amorphous blob that is “stress”.

DEVIKA:

I think the risk assessment is a good place to start. It frames the issue clearly: the risk to mom is very under-considered. Even when it is quantifiable, it's not given as much importance as the potential risks to a fetus or to a growing baby.

And because most of the elements that put mothers at risk are considered part and parcel of motherhood – self-sacrifice, martyrdom, sleep loss, stress, literal bodily engorgement [and other adaptations] – we don't privilege protection of maternal health around that peripartum period in the same way we do for the new child.

Yet we know that when the mom's health suffers, the health and wellbeing of the baby suffers. The health of the whole family system suffers!

MOLLY:

Such a good point.

With your expertise and medical background – you're a pediatrician – you come at this from a medical training that is built around prioritizing the baby and child. But, as you point out, even when your role in medicine focuses on children, you still need to see the impact of mom's health on baby's health.

Given the circular nature of how child health affects parent health affects child health affects parent health, would you say that, even with a medical focus on children, we could/should prioritize the mother?

DEVIKA:

For sure!

No child's health exists in a vacuum or on an island by itself. The most successful pediatricians are considering the entire family as who they're serving, [rather than just the child].

Pediatricians or other health professionals who are only focused on the baby's health are missing the majority of the influences on that baby's health.

MOLLY:

Let’s go back to the risk : risk analysis that heavily skews to low risk or even no risk to the baby alongside the ignored risk for the mother.

(Can we call it that? “Ignored risk”? Feels right, especially as it relates to stress… )

In terms of how risk : risk analysis shows up with medical priorities or parts of the journey (like breastfeeding), how can we better frame up maternal risk and stress?

DEVIKA:

That's a really good question. Take infant feeding/breastfeeding as an example. What's important for us to recognize is that there are maternal risks related to health that are quantifiable. For example, getting up every two hours at night. The risk [of disrupted sleep] is known.

“because most of the elements that put mothers at risk are considered part and parcel of motherhood – self-sacrifice, martyrdom, sleep loss, stress, literal bodily engorgement [and other adaptations] – we don't privilege protection of maternal health around that peripartum period in the same way we do for the new child.” — Devika

Often, we have this sense of, “oh, it's murky, it's hazy; we don't quite know what stress does to the body; we don't quite know what sleep deprivation does to the brain.” But we do! We can quantify these things. We know that wanting to breastfeed and having challenges with breastfeeding can lead to poor maternal mental health outcomes.

Similarly, we know that sleep deprivation, by itself, is a risk factor for worse health, both physical and mental health. We have all of this very clear data on risk to the mother. But the truth is, the guidelines around feeding by entities like WHO, the American Academy of Pediatrics, or ACOG (the American College of Obstetricians and Gynecologists), fail to present the risks to the mother with any real consideration.

I’m not here to say that there is one right option for any given situation or family, but I think that we owe it to parents, to kids, to the whole system, to intentionally quantify and weigh the risks to mom, to other caregivers in the family, and to baby when it comes to different feeding options and different ways of implementing and supporting those options.

I love the paper that you cite about prescribing sleep in the peripartum period. They have a graphic that you and I would completely agree with but is actually a fairly novel and groundbreaking way of thinking for many pediatricians and OBs who are trying to set families up for success in those early weeks. The concept focuses on consolidated, larger blocks of sleep of at least one 4-5 hour period of overnight and how that consolidation is super protective from a maternal mental health perspective. That means having a second person who is available at night to make sure that mom can sleep for that 4-5 hour stretch is critical.

Shifting how we think about it – how we resource around sleep protection at the individual level and more broadly at the societal level – is huge. It’s factoring in the cost of having a night doula or the “cost” of having your partner step up at night. And most of the time, they are back at work (if you're in your heterosexual relationship, 95% of the time, the man will be back at work in two weeks or less) so often it is their sleep that gets prioritized.

MOLLY:

Yes! The “whose sleep is more valuable?” question.

DEVIKA:

Exactly – and “whose energy and work is more valuable.”

At the end of the day, let's say we're in a situation where the man is going back to work at two weeks post-birth, and the woman, in a lucky case, is getting 12 weeks. All of the additional work the birth parent will do – which includes physical recovery in addition to the new role adjustments common to either parent – is a lot of added work. They need sleep protection more than ever to be able to do that work.

As you poignantly point out, they need sleep protection because they are postpartum. They are already at risk for poor health outcomes just by virtue of being postpartum — and we know that sleep deprivation sleep deprivation in the postpartum period has particularly acute impacts for driving poorer mental and physical health. So why is it that we tend to privilege and protect the non-postpartum parent’s health and sleep needs over the other?

MOLLY:

100%! I want to bring in the thread of your personal story because it perfectly positions the questions: what would it look like if we started from the point of prioritizing mom's health first? And what would it take to do that?

Breastfeeding and sleep, viewed through your story, provides a great example of how we can nuance individual consideration; how we can (and should!) change the way that broader recommendations play into healthcare. (The latter is obviously a loftier goal.)

“Why is it that we tend to privilege and protect the non-postpartum parent’s health and sleep needs over the other?” — Devika

How do we start building a logic flow from the available data points – from the research and the studies that make clear connections? For example, as you point out in your Slate article, we know that sleep disruption is destabilizing, especially for those who are at a high risk for mental health episodes. The logic flow could start from: we know sleep disruption is especially dangerous for those at high risk…

First consider: “what is going to disrupt your sleep?”

The obvious answer: Waking up during the night.

Then ask: “Why are you waking up during the night?”

If the answer is: I need to feed the baby.

Then explore: “How can you avoid waking up to feed a baby?”

Answer: Have someone else on night duty.

This logic flow tends to lead to a point where you cannot or should not rely on breastfeeding. It’s impossible to avoid night duty if the baby is dependent on your breast. If you follow that logic flow, it's a pretty simple answer. But it's not an easy one to make. When the care flow starts from breast is best, then you have to dismantle so many elements to work your way up to prioritizing maternal sleep protection. How do we reset and follow this different logic flow? Or maybe the question is – how should we change the conversation?

Can you talk more about your experience and how you approached it with your own medical team?

DEVIKA:

Let me start by setting up the background. I live with bipolar II disorder. One of the biggest risk factors – for mood disorders in general, but, especially in the bipolar spectrum disorders – is any kind of shift in circadian rhythm. For example, jet lag, working night shifts and switching into day shifts, working extended shifts in the hospital when you’re awake for 30+ hours in a row. All of those disruptions end up being very problematic for folks who live on the bipolar spectrum.

One of the biggest pieces of advice that [patients on the bipolar spectrum] receive and try to implement is being as intentional about circadian rhythm stability as possible: sleeping around the same time every night, waking up around the same time every day, making sure that the number of hours of sleep is both adequate but also high-quality, and trying to do what we can when we know that there's going to be disruption to try to put protective measures into place.

“When the care flow starts from ‘breast is best’, then you have to dismantle so many elements to work your way up to prioritizing maternal sleep protection.” — Molly

When I was planning for my first pregnancy, I had been living with bipolar II disorder for a number of years, managing it as a chronic condition and living well with it. Having had the gift of stability, I was especially nervous to enter this biologically high risk period by virtue of all the hormonal shifts, the sleep deprivation that comes with being pregnant and being peripartum. Even independent of any sleeplessness related to feeding choices, sleep issues are just part of the peripartum journey. I knew that, based on the numbers alone, I had more than a 50% risk of relapse during that period of time. That really motivated me to do whatever I could to modify that risk.

My psychiatrist, even before I was pregnant, made the most fervent recommendation: “It's gonna be hard. There's gonna be a lot that we can't predict. Let's stay on your meds. And let's think about how to protect your sleep, especially in the first three months postpartum.”

What did it mean to protect sleep in the first three months postpartum? The first part of my psychiatrist’s recommendation: invest in getting a night doula. Eliminate the expectation that one adult in the home would be up feeding the baby all night.

You might think that that's a really big expense (and it is) but we need to consider that even one untreated mother, one child of a parent who has postpartum depression, could cost a family up to $32,000.

MOLLY:

It should be covered by Medicaid!

DEVIKA:

Right. And think about the longer-term impact on health, on wellbeing and productivity, now you are reaching into the millions or billions. It's a cost that's well worth investing in.

For the second part of my psychiatrist’s recommendation, she said: “Look, I want you to think about what it would look like if you just didn't breastfeed at all. Just a thought exercise: baby comes out and you are using formula so, whenever you want, you could just go to bed. There are many other adults who are available to feed your baby.”

This was a hard pill for me to swallow as a ‘breast is best’-trained pediatrician.

I did try to push back a bit with “couldn’t I just breastfeed during the day and sleep at night and have enough pumped milk to make it through?” because I was initially really committed to the idea [of breastfeeding]. But we talked about the reality of breastfeeding and how that’s not actually how breasts work. [In the beginning, when I would be most vulnerable,] I would still need to pump every 2-3 hours, including overnight, to induce and keep up supply.

So, finally, I agreed: breastfeeding was definitely not going to work for my postpartum mood stability.

“This was a hard pill for me to swallow as a ‘breast is best’-trained pediatrician.” — Devika

For me, for any parent, you want to enter parenthood feeling 100% like yourself. You want to be able to be there for your kid, there for your partner, able to bond, able to emote. It was not an option for me to increase my risk [for a relapse], and I wanted to do literally everything that I could to try to control that risk. Given all of what I knew, I chose to not breastfeed, I chose to get a night doula, I chose to stay on my medications and monitor them very carefully and had the option of adjusting doses throughout.

I was really lucky that there were no persistent mood episodes [in the peripartum period]. There were no major setbacks in terms of my own health. That was such a gift. It's hard to quantify, but I would say at least 60%-70% of that was about sleep protection.

MOLLY:

Knowing that now is so important. But you still had to go through so much before getting this perspective. All the steps to wrap your head around how important this was, how you were going to handle it, what you were going to do. Then making the plan, sticking to the plan, and dissolving a particular vision of how you might mother. That's its own thing, right? Coming to peace with the “I guess I'm not going to be breastfeeding”.

You went through so much to make that decision and stick with it! And even though you worked through all of this with your psychiatrist (and you are a medical professional!), you still faced an upstream swim in other ways. Can you talk more about the discussions you had with your OB and pediatrician?

DEVIKA

We have already talked a bit about how the guidelines that pediatricians and OBs use are incomplete. How the guidelines leave out the risks for the mom while over-emphasizing and over-interpreting the benefits to the baby.

The breastfeeding guidelines say, “the benefits to the baby include…” with a whole host of long and short term health benefits or boosts, which, when you sit down with the data, are mostly associational. There have been some high quality, randomized, controlled trials around breastfeeding that have shown the two known benefits to the baby. TWO clear benefits: 4% fewer gut infections and 3% less eczema for breastfed babies in the first year of life relative to not breastfed babies. That's it. All of the other stuff – any claims about enhanced intelligence or better parent:child bonding, relationship quality, any long-term health impacts like diabetes, asthma risk, obesity risk – are not borne out by the randomized data. They are not demonstrated benefits even though they're stated as such in the guidelines. So there's that.

On the mom side, we do know that there is lower risk for breast and ovarian cancer for moms who breastfeed relative to moms who don't breastfeed. Likely because both of those are hormonally linked cancers. Otherwise, there's no other known benefits [of exclusive breastfeeding] for mom's health, either.

However, because of the absence of training and adequate consideration of the risks on the mom's side, most OBs and most pediatricians consider any path that is not exclusive breastfeeding as second best. Even though that’s not what the data say.

In my case, I had a clear recommendation from my psychiatrist and I was prepared to do what I needed to do. As an example, my psychiatrist's consulting question to the lactation consultant was: Can you teach Devika how to shut down milk supplies in the way that would make it least painful for her to close off this part of her journey? Even with that, when the lactation consultant came in the day I delivered she immediately did her standard: “Here's why breastfeeding is great. Here are the positions I recommend for you,” and then added “Do you at least want to try it for a little while and see how it goes before we move to shut down supply?”

When my psychiatrist, who's a perinatal expert, came in to visit me and heard about this, she was outraged. She went and spoke with the department to explain that this was the opposite of what we had asked for – “How dare she come in and talk to my patient and make her feel like she is doing the wrong thing?” We had a second consultant come in who gave me the information I was actually seeking.

“Because of the absence of training and adequate consideration of the risks on the mom's side, most OBs and most pediatricians consider any path that is not exclusive breastfeeding as second best. Even though that’s not what the data say.” — Devika

I also had somewhat of an uphill battle with my pediatric and OB providers, who were also chagrined and wanting me to consider breastfeeding. Again, they're not trained to consider the [real risks to maternal health, such as from sleep loss, routinely as part of establishing a feeding plan]. Even when the risk is quantifiable, it's just not part of the equation that they're trained to consider.

MOLLY:

So even though the “risk” to the baby is based on data that is either minor, or still being determined, this grey zone of any potential “risk” to the baby still outweighs the real risk to the mother. Your case had clear maternal risks!

We've grounded clinical care flow, we've grounded language, we've grounded the priority and how we talk about it all around the baby, only. Even though it isn’t based on a robust wealth of knowledge that exclusive breastfeeding is truly the only “best” way to feed. We don't have the data to say that.

DEVIKA:

We really don’t.

MOLLY:

And we don't have data showing an overwhelming risk to the baby of not breastfeeding.

DEVIKA:

Yet we make moms and families, but mostly moms, feel so bad if they can't figure out breastfeeding. Even though, like you said, we don't have data that not breastfeeding is bad for the baby, in any real way.

MOLLY:

Thinking about the narratives. The breast is best narrative. Even the fed is best narrative.

I understand that fed is best was a way to counteract the impacts of breast is best, but even that narrative centers the baby. Fed is best still puts the choice and puts the shame and puts the guilt of those feeding decisions back on the mother. (It should be parents, generally, but let's be honest, it's the lactating parent, which is usually the mother.) Someone is responsible for the choice and that someone is absorbing that message and what that means to their journey as a parent. They are absorbing how it fits into what they wanted or expected and how the rest of the world will respond to their choice.

What would it take to just throw those narratives out the window and start from the maternal risk logic flow? Start from prioritizing the mother’s health. Start from supported is best. Emphasize that her health is the most important thing?

The thing is, we could prioritize the mother’s health and still get to the point of exclusive breastfeeding (especially if she doesn't have high risk factors that are affected by disrupted sleep) and then the focus would be on providing the right lactation support, the right tools, the right education, the right language about how to breastfeed and how to help her feel good about the experience. Wouldn’t that be a healthier way to do it, all around?

“What would it take to just throw those narratives out the window and start from the maternal risk logic flow?

Start from prioritizing the mother’s health. Start from ‘supported is best’.

Emphasize that her health is the most important thing?” — Molly

What would it take to center the mother or prioritize her health – from the research perspective, from medical culture perspective, from societal perspective? What would it take to get there?

DEVIKA:

We definitely need to get there.

I love how you point out that even fed is best places the entire focus on the infant, rather than on the unit or on the mom.

We need to start from a place of ‘what is going to be the most health promoting for this dyad? For this whole family unit?’ That's where we start getting creative. If we become really myopic and only focus on perceived or even purported health benefits for the baby, and we ignore all the other pieces of the puzzle, we are going to land in the wrong place [and could ultimately adversely impact the health of the infant]

It's really short-sighted for our culture and our political system to think that you can have one person go to zero – in terms of maternal needs and maternal energy and maternal health – and still sustain the health of the unit. That's just ludicrous.

MOLLY:

There is also short sightedness in how maternal martyrdom feeds off of the narrative that “it's only for a short period of time” and “it's only this hard for the first month or three months or a year or whatever”. We have to push back on that and emphasize how that window of time could have long-term health effects that we don't fully understand yet.

“It's really short-sighted for our culture and our political system to think that you can have one person go to zero – in terms of maternal needs and maternal energy and maternal health – and still sustain the health of the unit. That's just ludicrous.” — Devika

We hear too often “it's only a short period of time”/ “this is normal” / “this is parenthood” / “welcome to motherhood.” The way we casually dismiss the cost to ourselves and our body and the experience of mothers around us, is really setting us back at a point when changing this narrative is so key to how we move forward.

DEVIKA:

In the sleep protection article that you pointed me to, they cited a really fascinating study that looked at cellular aging in medical interns and found this dose-dependent relationship between the number of hours worked per week and increased telomere loss. It basically started with “we know that medical residency is hardship…” but then showed how this short window of time sped up biological aging. Residents who averaged 75 hours per week for one year of training, one year of their entire life, had their telomeres shortened by the equivalent of losing several years of life. From ONE YEAR of working 75 hours per week in that intense pressure cooker, you have years of life lost!

[And likewise, we also know that sleep loss in the first few months postpartum also accelerates cellular aging.]

MOLLY:

We're slowly killing ourselves! That’s a great example of narrative and the need for culture shift too! How do we actually see the long-term impacts of these short-term sprints? Just having that embedded in the culture, the narrative of: “this is short”, “everybody does it”, “everybody did it before you,and everybody will do it after you”. In the case of residents, at some point, you have to break that cycle and say: “we're medical professionals. This is unhealthy. This is not good for us. This impacts our lifespan.”

I think that's so interesting to think about that culture shift. But it’s a hard ship to steer.

DEVIKA:

Interpolating that back into the maternal health discussion, it goes back to what you were saying before, how people will say “it's no big deal. Everyone does it. It's just a few months of your life.” But we don't actually know the long-term impact of taking on this load.

MOLLY:

And as narrative relates to sleep – we don't normalize dads losing sleep the same way we normalize it for moms. I think that's part of it too. If sleep loss is “normal” in early parenting, it should be normal for both parents to lose sleep. I do know some examples where individuals and workplaces respect the normalization that “this guy is sleepy at work because he has a new baby”, but I know a lot more examples where the priority is full sleep protection for the dad. Going so far as stories where the dad will sleep in another room so that he can't even hear the baby noises that might disturb his precious slumber. If we're gonna normalize that babies keep you up at night, let's normalize it for everyone.

“The way we casually dismiss the cost to ourselves and our body and the experience of mothers around us, is really setting us back at a point when changing this narrative is so key to how we move forward.” — Molly

Of course, if the non-birth, non-lactating partner is at high risk for something that is driven or exacerbated by sleep disruption, yes, protect their sleep. The question should come down to health: whose sleep do we need to protect and why? Who has the heightened health risk when it comes to sleep loss? That should be part of the narrative too.

I keep coming back to breastfeeding and sleep as the starting point for considering all of this because it has such clear connections, as your story demonstrates. Beyond breastfeeding and sleep, though, there is so much carry over into how this shows up at all points – how we prioritize baby over mother during pregnancy, how we prioritize kids over mother at every point afterwards. Interrogating this part of the story frames that this is just an example of how these lopsided priorities show up everywhere.

DEVIKA:

100%

Not only are those several months after a child is born important in terms of the impact that we can have on maternal health down the road, but those early months are also important for how you get set into ways of interacting with the baby and task division in the household. It is really hard to undo those things once they get set.

MOLLY:

Back to the cultural narrative – similar to how breast is best / fed is best centers the baby (and we don't actually see the mother in the equation yet it puts everything onto her), in pregnancy you have a similar narrative. The “healthy baby” narrative; the “all I want is to have a healthy baby”. I feel like I hear this a lot.

“We're not giving families a menu of options, we're giving them one right choice and making their lives hell if they want to choose something else.” — Devika

It sets up a form of maternal martyrdom and it also frames medical decisions and care flow, going into birth and after birth. When the focus circles“all I want is a healthy baby,” what does that mean for the mom? What does it mean if mom is dead on the table, or traumatized, or experiencing complicated emotions from all the things that can happen during birth, but the narrative is “all you want is a healthy baby” and the baby is fine? The outcome is what she wanted, so everything should be ok? To me, especially in this political atmosphere, that feels really dangerous.

DEVIKA:

It feels like the mom is just a vessel and their health and well being is secondary in these narratives.

MOLLY:

Do we have hope for how this can change, even given the current atmosphere?

DEVIKA:

I think the change in these kinds of disruptive narratives begins in conversations and in circles like ours. Once there's enough noise about there needing to be a different way of thinking about it and a different way of approaching it, then it percolates into the more systematized and structural drivers of these kinds of changes – like the regulations and the guidelines, and the medical training apparatus. All of those changes will take decades more, but I think it really does start in grassroots ways.

I think it starts with women and men and families asking for a different way of doing it. Just to take that breastfeeding/feeding example, we're not giving families a menu of options, we're giving them one right choice and making their lives hell if they want to choose something else. That's not fair.

MOLLY:

That's not fair.

We have work to do! To change the narrative, start the cultural shift, have the conversations, support each other through all of it without judgments.

DEVIKA:

Make each other feel validated and heard even when it feels like we are one of the few voices who are going against the fray.

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Read more from Devika on her Substack:

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