In the last 80+ years, the role of families surrounding infant feeding have been systematically changed as a result of urbanized populations, specialized medical practice, and commercialization (profitized) infant feeding. In the last 5 years, there has been unprecedented support for breastfeeding from all levels of government, professional organizations, consumer rights groups, and from parents themselves. This change is auspicious as background making PAMS growth and establishment possible, driven almost exclusively by participants as consumers and change agents. This change in the way that breastfeeding and the provision of human milk are seen throughout the socio-political spectrum provides some interesting observations and poses some unique challenges. I have the pleasure again this week of including observations and considerations from Elizabeth Brooks JD, IBCLC, FILCA.
Lewin’s Theory of Change
Lewin proposes that everything exists in a field of opposing forces. In the case of PAMS-
Driving Forces – Consumers of healthcare policy and professional guidance, i.e. infant families choosing to participate in milk sharing by private arrangement. Milksharing networks and advocates are also driving forces, however, within the context of policy entrepreneurship the personal interest of networks must be taken into consideration in addition to the value of contributions to change supporting consumer demands (Kingdon, 2010).
Opposing Forces – Profit seeking entities (milk cooperatives and for-profit milk banks), the the Human Milk Banking Association of North America, United States Food and Drug Administration, and individual healthcare providers are just a few of the major opposing forces of PAMS. Self interests must again be considered. Lack of knowledge and consideration of the practice not only on merit of the practice of PAMS, but as a result of marginalization of the personally identified importance of agency and autonomy in infant feeding decisions contribute to these opposing forces (Kingdon, 2010; Akre et al., 2013).
Policy regarding PAMS is currently in the Movement phase of Lewin’s model. It is during this phase that the nature of change is defined, and the abilities of change agents challenged. The consumer driven infant feeding intervention of PAMS puts individual participants as consumers of healthcare in a difficult position at the curl of the wave of change. In speaking with Brooks about the unique aspects of the consumer-turned-change-agent in individual decisions and more broad social change, it was made clear that there is no singular way of making change. “They [effective change agents] look like folks who can persuade decision-makers to come to the result the change agent seeks. In healthcare, the needs and wishes of the patient/client (“consumer”) are supposed to drive informed decision-making and care planning.”
Difficulty arises when this foundation of consumer driven healthcare and individualized evidence informed practice fail to be realized in reality. Participants have found themselves in precarious positions where they are expected to be consultants and educators to their healthcare providers regarding their decision to participate in PAMS. Media and even recent academic coverage of alternative sources of human milk have only raised the difficulty in navigating the movement and continuing to drive forces of change toward acceptance of PAMS as part of the infant feeding spectrum of choices. According to Brooks, “[T]he consumer is often the least empowered to see this happen. Any issue that the mainstream media or healthcare establishment perceives as “risky” will add extra layers of difficulty in getting to a well informed discussion and decision.” This, I believe, is the proverbial cue for research and academia to contribute in the way of evidence to bolster and clearly define merits and challenges of future policy development and change (Kindon, 2010).
Criteria for Survival
Per Kingdon, the primary criteria for survival of a new policy (Refreeze) is a test of public acceptance (2010). Considering the relatively minor number of families currently participating in PAMS, this test is likely going to be a long one. Government at all levels and agencies of the private and public sector are priding themselves on innovative solutions and meeting the needs of consumers, as the consumer defines those needs when and where evidence supports change (Liebman, 2013). Commitments have been made in adapting funding for research into initiatives, programs, innovations, and solutions originating in a variety of sources, and with scalable implications (Liebman, 2013). PAMS has demonstrated a moderate degree of scalability since its inception, and certainly fills a need expressed by consumers for a source of human milk that is immediately and realistically obtained. Support for the provision of human milk exists in policy, practice, and evidence in formalized contexts. The critical gap with PAMS in relation to Liebman’s position and exemplars regarding recognition and funding for viability is the current insufficient evidence regarding specific characteristics of the practice to evaluate efficacy in bridging a gap created by other complex inequities in access to support for lactation and provision of human milk.
Progress is being made in defining the practice, resources, and realities of PAMS by myself and others in academia in many contexts related to PAMS. As these pieces come together, it is my sincere belief that a case will be made for PAMS as a viable option for families seeking to provide human milk in the absence of sufficient milk from a biological parent. Participants as consumers of healthcare and agents of change in PAMS health policy are likely to blaze their own trails in creating solutions to their individual infant feeding needs and beliefs. I applaud the commitment and dedication that it takes for donors and recipients alike to contribute so meaningfully to a practice that creates such an opportunity for dialogue regarding the role of policy and agency in healthcare.
Brooks, E. (2014). Personal Correspondence.
Kingdon. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2nd ed.). London: Longman Publishing Group.
Liebman, J.B. (2013). Building on recent advances in evidence based policy making. Brookings. Washington, DC. Retrieved 3/2014 from http://www.brookings.edu/research/papers/2013/04/17-liebman-evidence-based-policy