Martha Rider Sleutel, PhD, RN, CNS BREASTFEEDING DURING MILITARY DEPLOYMENT. A Soldier s Story

Martha Rider Sleutel, PhD, RN, CNS BREASTFEEDING DURING MILITARY DEPLOYMENT A Soldier s Story

Women are heavily involved in American national defense. There are currently more than 200,000 active duty women serving in the U.S. military, comprising more than 14 percent of the active duty forces. Combined with reserve and National Guard forces, this number rises to approximately 330,000 women, with the majority being of childbearing age (Department of Defense Personnel and Procurement Statistics, 2011; U.S. Census Bureau, 2011). Forty-three percent of active duty and reserve members have children, and the majority of those children are in the age range of newborn to 5 years. A total of 272,885 children of active duty mothers (22 percent) are 2 years of age and younger (Department of Defense [DOD], 2009a). Abstract: Thousands of women of childbearing age are serving and being deployed in the United States military. U.S. Department of Defense policies related to breastfeeding and deployment are inconsistent among the different branches of the military and sometimes conflict with evidence-based guidelines about optimal breastfeeding practices. This is the story of an active duty soldier who was deployed while breastfeeding and the obstacles she encountered trying to send breast milk home to her son. The article explores policy, health and professional practice implications. DOI: 10.1111/j.1751-486X.2012.01696.x Keywords: breastfeeding deployment military policy

This article describes the experiences of a breastfeeding deployed soldier, and explores relevant facts, policies, standards and practice implications. The military member, Captain B., was an Air Force family practice physician with a 7-month-old breastfeeding son. Stationed at a base in Texas, Capt. B was deployed to Afghanistan in 2007. The story of her efforts to get breast milk to her son during her deployment includes obstacles, adventures and an administrative comedy of errors. This story illustrates policy and practice implications, as well as opportunities for professional advocacy. CONFLICTING POLICIES After giving birth, military women generally have their deployments deferred for 6 to 12 months postpartum, depending on the branch of service. No comprehensive DOD policy exists regarding deployment of breastfeeding mothers and each service has different rules (DOD, 2009b; Roche-Paull, 2011). In the Air Force and Army, women are eligible for deployments 6 months after giving birth, regardless of breastfeeding status, while Navy and Marine Corps policies defer deployments for 12 months after birth. A recent DOD report on support for military women examined these policy differences, but provided no justification other than to provide discretion to military service branches related to readiness and manpower (DOD, 2009b). Only the Navy s and Marine Corps policies of deferring deployment for 12 months following birth are consistent with evidence-based guidelines from numerous professional and government organizations (American Academy of Pediatrics, 2005; World Health Organization [WHO], 2003). Research overwhelmingly affirms that breast milk is the optimal source of nutrition for infants. Differences in health outcomes are so striking that some scientists recommend that patient education materials should indicate that it s a health risk for infants not to receive breast milk (Berry & Gribble, 2008). Governments and health care organizations worldwide have similar breastfeeding policies. In the United States, the American Academy of Pediatrics policy guideline recommends that breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child (American Academy of Pediatrics, 2005, p. 499). The WHO has numerous publications and policy statements advising that mothers breastfeed infants exclusively for the first 6 months and continue breastfeeding up to 2 years and beyond. These policy statements are based on extensive scientific literature showing numerous health risks for infants, children and adolescents who were not breastfed as babies compared with those who were breastfed (Agency for Healthcare Research and Quality [AHRQ], 2007). Martha Rider Sleutel, PhD, RN, CNS, is an associate professor of nursing at Angelo State University in San Angelo, TX. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: martha.sleutel@angelo.edu. EMBARKING ON THE UNKNOWN As a family practice physician, Capt. B was well aware of the scientific recommendations and was determined to breastfeed her son for at least his first year of life. In accordance with these guidelines, her 7-month-old baby was gradually being introduced to solid foods when she received orders to deploy to Afghanistan. At that time (2007), Bagram Air Force Base (AFB) had limited services and was geographically isolated, but was being significantly expanded and modernized. Every deployment situation is different, and Capt. B had heard rumors of women who had been deployed to less remote sites, such as large bases in Germany, who had shipped their breast milk home. However, she had never heard of anyone shipping breast milk from the Middle East or from remote sites, and she didn t know what the conditions or work requirements would be at Bagram AFB. Considering those rumors, as well as the unlikely possibility of a quick return home, she packed her breast pump, in hopes of maintaining her milk supply. Leaving a frozen supply of breast milk, Capt. B breastfed one last time and boarded the plane to Bagram, Afghanistan. En route, she pumped anywhere she could find semi-privacy airport and airplane restrooms, tents shared with other women anywhere that was somewhat clean. She threw this milk away, trying only to keep her milk supply intact until she returned home. image DVIDSHUB, flickr.com 22 2012, AWHONN http://nwh.awhonn.org

ORGANIZING CHAOS AND ESTABLISHING A SYSTEM When she arrived at Bagram AFB, Capt. B was disappointed to see dirty, dusty conditions everywhere, which were completely unsuitable for pumping or storing breast milk. Her hopes were rekindled, however, when she saw the hospital where she would be working for the next several months taking care of injured soldiers and sick Afghani children and civilians. The hospital was new, clean and had private exam rooms. Most importantly, it had a large freezer that would enable her to freeze and store her milk. Coincidentally, one of her new colleagues was a nurse who was also a lactation consultant. This nurse provided emotional, informational and technical support that helped with the tedious process of pumping five times a day. her parents house, where her husband and children were visiting. This time, as she tracked the milk s progress, it was stopped by U.S. Customs and Border Security in New York for 3 days. After the milk shipment was delayed 12 hours, she called DHL, who contacted Customs, who told DHL that the shipment recipient (her husband) had to call them. As the sender, Capt. B couldn t get any information! This was a problem because both phone and Internet service from Bagram Air Base were unreliable. Trying to call the United States often required multiple attempts. In addition to a 10-hour time difference, connection problems made conversations difficult. While Capt. B could usually call her family, they couldn t call back, so they responded via e-mail. During the 3-day delay, Capt. B asked DHL to explain to Customs that it was essential to keep the There are currently more than 200,000 active duty women serving in the U.S. military, comprising more than 14 percent of the active duty forces After finding a place to pump and store her milk, Capt. B began exploring how to ship the milk back home. After researching available options for perishable items, she found that her first choice, FedEx, didn t ship perishable products out of the country. Her next option was the U.S. Postal Service on the base, but this was unacceptable because shipments took 7 to 14 days to reach the states. Once again, her hopes were dwindling. Then she heard of DHL, an international shipping company. Explaining the situation was almost comical since the workers at first couldn t understand why anyone would want to ship milk to the United States. Can t they buy milk in America? they asked. After further explanation, they finally understood and told her they could ship her milk in a cold compartment to the United States in 3 to 5 days. She bought a cooler and prepared to send her first shipment. She filled out the necessary paperwork and found out the flight times for the first trial shipment. To be successful, the breast milk needed to arrive at home still partially frozen and with the bags intact. SHIPPING BREAST MILK: A COMEDY OF ERRORS The Trial Run Shipping breast milk home turned out to be more complex than Capt. B had ever imagined. However, she was thrilled with the first shipping attempt. To her relief, the first shipment took 2½ days to arrive in Texas and there were no problems whatsoever. The milk was still partially frozen and in good condition. The total cost was $113. SNAFU (Situation Normal - All Fouled Up) Capt. B sent the second shipment to Marquette, Michigan, to cooler frozen, but she had no way of knowing if this was being done. After numerous convoluted efforts at communication, Capt. B obtained and sent the following documents to the various agencies to facilitate the shipment: Form 3299 - Declaration For Free Entry of Unaccompanied Articles, from the Department of Homeland Security website. A letter of urgency notifying Customs of the perishable nature of the milk, asking them to keep it frozen and to expedite its release. A faxed copy of her military ID, front and back, and copies of her military orders, as well as her husband s military dependent ID (this was a challenge with no fax machine on the base). IRS form for small businesses from the shipment recipient for Customs. During this process, Customs contacted Capt. B s husband with the same questions: What are you doing with this milk? Who is it for? Who is it from? Eventually, the paperwork was acceptable and the milk was finally delivered 5 days later, completely frozen, at a cost of $155 (cost was based on weight and there was more milk in this shipment). The next shipment included all the previously required paperwork to prevent any further delays. It took 4 days to arrive in Michigan, but half of the milk was thawed and had to be discarded. DHL refunded the cost of $169. Animal Product? Nonhuman Primate Material? The fourth shipment was held by the U.S. Department of Agriculture (USDA) in Ohio for 18 hours without explanation. After several calls to determine the reason for delay, Capt. B was February March 2012 Nursing for Women s Health 23

finally connected to a veterinarian with the USDA. This time, the regulation was Guideline # 1101 Importation of Human and Non-Human Primate Material (Animal Products That Do Not Require an Import Permit), requiring Capt. B to provide a signed statement that the breast milk was not infectious. The milk finally arrived in Michigan at the cost of $155. Successful Routines From that point forward, Capt. B included all the previously required forms with every shipment, along with copies of her military ID and her military orders. It was never clear why different regulations seemed to pertain to different shipments, or why the first shipment with minimal paperwork encountered no delays. With later shipments, there were often short delays by Customs, but the milk was released within hours. Capt. B sent shipments every 2 weeks and never experienced a decrease in her milk supply. The majority of the milk arrived still frozen and intact. Occasionally milk would have to be discarded if it was thawed or the bag was broken. COMBAT BREAST PUMP While deployed, Capt. B provided medical care to U.S. and Afghan soldiers, as well as Afghan civilians and national police. Many of the patients were Afghan children and women who were often either pregnant or breastfeeding. When breastfeeding mothers or infants needed surgery that resulted in separation, the mothers were at risk of losing their milk supply. Breastfeeding is the only source of nutrition for Afghan babies, since formula is expensive and not readily available. Also, few people have access to clean water necessary to mix formula or wash bottles. If a mother had to be separated from her infant, the infant had little chance of survival if the mother s milk supply was not maintained. Preserving the mother s milk supply by pumping the breasts is the standard of care in this situation, as it is for breastfeeding women in U.S. hospitals. Since the new hospital facility was not yet fully supplied, it didn t have a commercial breast pump. To meet this need, a trauma surgeon used existing supplies to create a makeshift breast pump, which they named the Combat Breast Pump. The components consisted of an ambu bag mask to provide a soft seal over the breast, suction and a suction collection device hooked to intermittent wall suction. This worked well for patients until the facility was able to acquire a traditional breast pump. HOME AT LAST Capt. B arrived home 8 days before her son s first birthday. He had received commercial formula for only a few days during Capt. B s deployment of 4½ months. He wouldn t breastfeed at that point, but continued receiving breast milk via a bottle. Capt. B continued to pump until she transitioned him to cow s milk 1 month later. DISCUSSION An increasing number of women are serving as soldiers, many in remote locations, which makes breastfeeding a daunting challenge. In addition to numerous health benefits, breastfeeding has economic implications, as well. The most extensive cost analysis to date estimated yearly savings of $10.5 billion and 741 preventable deaths if 80 percent of U.S. mothers breastfed exclusively for 6 months (Bartick & Reinhold, 2010). With health savings of this magnitude, it makes economic sense for U.S. military policies to support breastfeeding. IMPLICATIONS FOR NURSING PRACTICE Stories can be powerful teaching tools. While few nurses may be involved with military deployments, most nurses are well positioned to positively impact breastfeeding on multiple levels. On an individual level, sharing positive stories may inspire optimism and confidence for mothers facing difficult circumstances. They can also serve as a framework for teaching points. For instance, breastfeeding mothers facing separation from their babies may solicit help with weaning without considering strategies to main- Shipping breast milk home turned out to be more complex than Capt. B had ever imagined 24 Nursing for Women s Health Volume 16 Issue 1

tain their milk supply. Relating stories of success under adverse situations, such as Capt. B s, may prompt ideas and options that mothers hadn t considered before. After hearing about breastfeeding during a military deployment, mothers may view their separations as much more manageable by comparison. Breastfeeding success stories can be a planned intervention in hospital and education settings. Exposure to breastfeeding positively influences women s breastfeeding intentions and success (Angeletti, 2009; Meedya, Fahy, & Kable, 2010), while, conversely, mothers view working and workforce obstacles as a barrier to breastfeeding (Stewart-Glenn, 2008). Sharing accounts of breastfeeding achievements may help normalize an expectation that breastfeeding will succeed despite obstacles and work constraints. Since U.S. culture views military members highly, descriptions of breastfeeding by military members provide useful role models. Positive breastfeeding narratives can be a strategy to counter the adverse effect of widespread failure stories, which U.S. mothers typically encounter. Using stories to normalize success and counterbalance negative accounts can be a conscious, deliberate strategy for all breastfeeding advocates. Undergraduate nursing education, prenatal education, mother-baby and intrapartum units and even social situations provide opportunities to use this intervention. On a larger scale, women s health and perinatal nurses have power to influence health policy. Policies supporting new parents are much less generous in the United States than in other developed countries (Stewart-Glenn, 2008). Nurses can counsel patients and even contact legislators to offer facts about the societal benefits of breastfeeding. Nurses can correct misperceptions, explain health cost savings and support national breastfeeding strategies, such as those in the new health reform legislation. Nurses can advocate for military mothers by requesting that service branches have consistent deployment deferral policies supported by breastfeeding standards and evidence. Shaping social policy to improve health, such as by advocating for breastfeeding mothers, is a duty of professional nurses (American Nurses Association [ANA], 2011). CONCLUSION This is a story of a military soldier s perseverence to maintain her breast milk supply against great odds. It highlights one woman s commitment to follow evidence-based practice guidelines known to improve health. Her story illuminates an overlooked problem for military mothers. Unlike civilian mothers, military soldiers are not in a position to advocate for policy changes. Nurses and other care providers must advocate that research evidence be used not just in health care settings, but also in the development of national health and military policies. While sharing this story may inspire expectant or breastfeeding mothers, it may also motivate nurses and other care providers to make practice and policy changes on a larger level. NWH Acknowledgment The author acknowledges Kellie Turner, RN, CNP, for her enthusiasm and ideas during the initial stages of this project. REFERENCES Agency for Healthcare Research and Quality. (2007, April). Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD. Retrieved from http://www.ahrq.gov/ clinic/tp/brfouttp.htm American Academy of Pediatrics. (2005). Policy statement. Breastfeeding and the use of human milk: Organizational principles to guide and define the child health care system and/or improve the health of all children. Pediatrics, 115(2), 496 506. American Nurses Association. (2011). Code of ethics with interpretive statements. Retrieved from http://nursingworld.org/ MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/ Code-of-Ethics.aspx Angeletti, M. A. (2009). Breastfeeding mothers returning to work: Possibilities for information, anticipatory guidance and support from U.S. health care professionals. Journal of Human Lactation, 25, 226 232. Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics, 125(5), 1048 1056. Berry, N. J., & Gribble, K. D. (2008). Breast is no longer best: Promoting normal infant feeding. Maternal & Child Nutrition, 4(1), 74 79. Department of Defense. (2009a). Demographics 2009: Profile of the military community. Retrieved from http://cs.mhf.dod.mil/ content/dav/mhf/qol-library/pdf/mhf/qol%20resources/ Reports/2009_Demographics_Report.pdf Department of Defense. (2009b). Report to the White House council on women and girls. Retrieved from http://www.defense.gov/ pubs/pdfs/dod_whc_on_women_and_girls_report_personal_info_redacted_c82a.pdf Department of Defense Personnel and Procurement Statistics. (2011). Military personnel statistics. Retrieved from http://siadapp.dmdc.osd.mil/personnel/military/miltop.htm Meedya, S., Fahy, K., & Kable, A. (2010). Factors that positively influence breastfeeding duration to 6 months: A literature review. Women and Birth: Journal of the Australian College of Midwives, 23(4), 135 145. Roche-Paull, R. (2011). Breastfeeding in combat boots: Military policies. Retrieved from: http://www.breastfeedingincombatboots. com/military_policies.html Stewart-Glenn, J. (2008). Knowledge, perceptions, and attitudes of managers, coworkers, and employed breastfeeding mothers. Journal of the American Association of Occupational Health Nurses, 56(2), 423 429. U.S. Census Bureau. (2011). National Security and Veteran s Affairs. Facts for features: Women s history month, March, 2006. Retrieved from http://www.census.gov/compendia/statab/cats/national_ security_veterans_affairs.html World Health Organization. (2003). Global strategy for infant and young child feeding. Retrieved from http://www.paho.org/english/ad/fch/ca/gsiycf_infantfeeding_eng.pdf February March 2012 Nursing for Women s Health 25