It's not quite accurate to say that the systems for maternal health in the United States are broken… but it does seem fair to note that they can sometimes suck. Which is why, this April, a group of business leaders, innovators, academics, civic designers, and community leaders are getting together for the Make the Breast Pump Not Suck Hackathon and Make Family Leave Policy Not Suck Summit at MIT's Media Lab. The idea is to get some ideas flowing around systemic improvements to maternal health that will eventually create a more holistic and supportive environment. There is much to say here, and to get you thinking about it all, we've convened Catherine D'Ignazio, this project's Executive Director and a Faculty Director at the Emerson Engagement Lab, and Continuum's Jen Ashman, a Senior Designer who led the team in designing the Medela Sonata™ smart breast pump experience. Their conversation is wide-ranging, honest, and informed—and it does a fine job in setting up dialogic solutions to the many, complicated problems facing this space. Is it the mother of all healthcare challenges? Scroll down and find out. And then, when you're done, call your mother!
Breast Milk Is Magical
Jen: One of the things that I found really amazing about our work with Deanna Gilbert and the Medela team, for the project we did at Continuum, was the notion that "Breast milk is magical." I had no idea at the time—I didn't have a baby then—how breast milk can change from day to night, how it can give you different nutritional properties for your baby. I'm just curious: What's your perspective on breast milk in general?
Catherine: Well, I shouldn't disclose this, but the password to our Twitter handle is "liquid gold." So now we're going to have to change it. But, yes, I totally agree with the "breast milk is magic" idea and on the page for the 2014 Hackathon, in our FAQ, we had the question: "Why is breast milk magic?"
How do we make it possible for all babies to enjoy the benefits breastfeeding? How can we help parents, who are trying their best to do right by their child, to make it so that they can actually realize this magic?
Discovering the awesomeness of breast milk was, for me, part of the trajectory of becoming a parent. At first, I had planned to breastfeed because that's what people said you should do. What was surprising to me—and I also had a lot of doubts, obviously, as a first-time-parent—was that I didn't anticipate the extent to which I would fall in love with my child, and also the extent to which, in a way, I fell in love with breastfeeding and the breast milk relationship-even through all of the struggles—because my journey was not at all painless.
For me, the experience was so positive. I also love science and I love learning about what's going on in my own body, so I got deeply obsessive into breastfeeding for a while. I wanted to do the CLC course and become a lactation consultant. Because, as I was learning all these things—there are all these amazing benefits that breast milk has (they call it the "perfect medicine") and when the mom's immune system reacts to something, the breast milk automatically produces those antibodies which then flow to the baby so that the baby doesn't get ill—I thought: "That's just magical." I learned that some of the bacteria in breastmilk actually have no nutritional value for the baby, but they're nutrition for the bacteria in the baby's gut. So, you're actually contributing to the baby's microbiome, not actually building up their bones but building up their immune system.
As I went through that whole journey and fell in love with breastfeeding, I also saw myself struggle, and saw lots of people I know struggle, and thought: How do we make it possible for all babies to enjoy the benefits of breastfeeding? How can we help parents, who are trying their best to do right by their child, to make it so that they can actually realize this magic? And without sentimentalizing it.
Jen: Right, making it naturalistic.
Catherine: Then it creates this idea that "Breastfeeding is natural" and "It's going to be so easy."
Jen: Which is not true.
Catherine: Which is not true at all.
Jen: Which isn't even how it started. Back in the 1900s, breastfeeding was considered something that a nanny did. And then, all of a sudden, after World War II it was considered "not good enough." You had to have formula to make nutrition worthwhile. On the Medela project, we were exposed to both a European perspective and an American perspective in our research, and we saw how different those were, in terms of having a holistic view of breastfeeding.
In Europe, quite often you get a year's worth of maternity leave, which does enable a lot of moms to actually go through figuring out their journey. They don't get it all right all the time, but they have time and freedom to figure out what's the right balance in terms of "Do I want to breastfeed today? Do I want to support with formula? Do I need to go outside and get some fresh air?" The other difference that I found is that, quite often in Europe, midwives are with you throughout the entire journey, or a doula is with you. They're coming to your home for a year, seeing how you're doing, not necessarily requiring that you go to a hospital or go to your doctor's office, or you go to your pediatrician's office.
Catherine: This is exactly the model that one of the members of our advisory board, Eva Zasloff does. She's an MD, a family doctor, and she does what she calls "Fourth Trimester Family Practice." And once we learned about her model we said: "This is it. This should be the default." Once you have the baby, [a practitioner] comes to your house, she does all of the tests, she weighs the baby every x-days, she checks the mom, she provides lactation counseling and support, she stays with you, she gives you her time and she counsels on postpartum mood and mood support. She goes to you and cares for you—
Jen: —in the comfort of your home.
Catherine: In your home, so you're not, four days later, picking up a 40-pound car seat.
Jen: With your crying child.
Twenty-five percent of new moms in this country go back to work 10 days or less after giving birth.
Catherine: With your child, who's crying uncontrollably because they're not in the arms of their mother. And then trying to heft it into the backseat, drive to the pediatrician's office, it's Boston, it's snowing, there's slush everywhere, there are some risk of you falling, you're probably bleeding. And then you're in the doctor's office and there are germs and sick kids everywhere. Why is this our model?
And this is where I think Eva really has it figured out. And now we're trying to think: How do we make her model the default, because she can only see x-number of patients per year?
Jen: All of a sudden, that's more than just mom and baby. Now doctors are involved, a nutritionist, a midwife, a lot more people.
Catherine: Why couldn't that be the default model? That's where I think the Europeans have it much better figured out than we do.
Jen: Which is fascinating because when we did our research, going to these European parents' houses, all of a sudden it wasn't just mom. She was definitely the head of her team, but she had dad jumping in, he had parental leave for six to eight weeks. The whole experience was much more about community. We found that one of the number-one triggers for confidence for new moms was this idea that "My team is with me" and "I have the support and it's not a burden on them."
Catherine: That's amazing. Here, as we've been planning our paid family leave summit, we've learned some truly terrible statistics. Twenty-five percent of new moms in this country go back to work 10 days or less after giving birth.
Jen: They don't even take maternity leave.
Catherine: They don't even have it, which is insane. And only 14 percent have access to paid leave. This is also why I think we see so many problems develop in this postpartum timeframe. We're talking on a broad level.
Jen: Postpartum depression.
Catherine: Yeah, postpartum depression, because people feel alone. Also, a lot of people live far away from their families, so their families might not necessarily be able to be present with them.
Jen: I'm in that group.
One of the things that's interesting about the Amazon case is they have a specific policy for before the birth. They give you up to four weeks of leave, paid, before the birth.
Catherine: I know, me too. My parents live in North Carolina. For a lot of the people we've interviewed so far, there's this constant feeling of stress that says: "You have to make a sacrifice one way or the other. You either have to sacrifice something about your child, your child's health, or your relationship with your child so that you can put food on the table and have a house, or you sacrifice your housing or your food situation to be with your child." That shouldn't be the choice. The choice should be whether you want to breastfeed or not.
Jen: How do you want to be empowered or empower your baby? I think that's an interesting question as well. At Continuum, we work on a lot of different projects, and I'm finding out, on one particular project about the workplace, over 50 percent of people are expected to become freelancers by 2020. And that means working from home, working from cafes. If the workplace question changes, so do the questions around maternity leave. As a freelancer, how much access do you have to unpaid leave? None at all, I'm assuming.
Catherine: That's super interesting. It's true, the whole nature of work is changing. I feel like it points to the need for a solution that's maybe beyond just employer-based leave.
Jen: I think you just hit it.
Innovative Policy: Implementing a Cultural Shift
Catherine: Our policy advisor, Binta Beard, has been helping us put together our Make Family Leave Not Suck Policy Summit. We've been talking with her about "big P" policy, meaning public policy, and "little p" policy, meaning what employers do. And of course, the "little p" policy is super important, especially if you're a large employer like Wal-Mart or Amazon. It's really important what you do because it affects a lot of people. But then, we can't solve all our problems by trying to change certain practices in corporations. Certain companies are incentivized to do it. We see some really interesting leadership with tech and financial companies giving really generous paid leave.
When you choose to either pump or breastfeed or both, you're making a huge sacrifice. You're spending a lot of time, you are investing a lot. A lot of women, especially women in the workplace, feel shame. You're hidden in some server closet or bathroom with an old mop or something.
Jen: You mentioned Amazon a while ago.
Catherine: Amazon actually has a really interesting story. We've talked with them, and they kind of messed up their first time around and then they came back and designed a very parent-centered policy based on focus groups. It's really innovative. But the companies that can do that, again, are going to be the ones that have the resources to make it happen.
Jen: Potentially a much smaller market. Versus "big P" policy, which seems like it would also be less transitory if it's enabled and enacted.
Catherine: You would just have it, as a freelancer, because the federal government would say: "Everybody gets three months of paid leave and the payment comes in the form of salary replacement, at 100 percent." That's why we chose to focus on paid leave specifically, because the folks that we've been talking to say that it's the number-one equity issue. It's the number-one barrier to the breastfeeding relationship, whether or not moms and parents have time to spend with their babies. If you don't have the time off, then it's going to be very difficult to succeed at breastfeeding. We see people do it. We've heard from lots of people that make it work. Moms that have to return to work 10 days later and who then don't end up getting the latch right, but then they become exclusive pumpers, and then are insanely dedicated to exclusively pumping—which is amazing.
Jen: That time is so intense—but it's pretty short in reality, for that amount of intensity.
Catherine: It feels long, but it's short.
Jen: So, anything that makes it better is a breath of fresh air.
Catherine: A cultural practice I've been inspired by, I think it's in Asia, maybe China, is this: There are 30 or 40 days where the mom and the baby are not supposed to leave the house.
Catherine: Yeah, it's this period like incubation, almost. It feels like a fourth trimester. Until very recently, you and the baby were the same person, and now you're slightly separated, but you're still going to take some time, incubate each other, figure this thing out together before you go out and get more public with everything.
Jen: The beauty of that is all of sudden, it's not a pressure on the mom to feel like "I need to reclaim that time!" It's enabling and given to her so that she can feel supported. In our research, I heard moms talk over and over again about the guilt they feel when they go back to work and take time away from being with their baby. My stepmom is Chinese, and when she had her two little twins, right before the birth, she went through this 30-day period of pure relaxation, massage, and just luxury.
Catherine: That sounds amazing.
In the U.S., people are working up until the day they give birth. Because if they take any leave prior to the birth, then they are penalized on the other side with fewer days to spend with their baby.
Jen: Pre-baby rest sounds like a good idea.
Catherine: Whereas in the U.S., people are working up until the day they give birth. Because if they take any leave prior to the birth, then they are penalized on the other side with fewer days to spend with their baby.
Jen: And if you think about the stress that happens in that flex of working all the way… sure it gets you out of the house, which is great, but stress is a key factor in keeping moms from being able to produce milk.
Catherine: And stress, we know, is also not equally distributed. There are these huge equity issues within that as well.
Jen: That makes a lot of sense.
Catherine: One of the things that's interesting about the Amazon case is they have a specific policy for before the birth. They give you up to four weeks of leave, paid, before the birth. That's the first time I've heard of a policy specifically for that. Say your baby is premature, or say they get put on bedrest: You can take that time, and have your pay, not be stressed out, and still know that you have all the remaining weeks on the other side.
Jen: You're not sacrificing anything.
Jen: What's beautiful about that is that it's not just human-centered, it's emotionally and physically relevant to a mom. This is the time where her life changes completely. All of a sudden, she's no longer either by herself, if it's the first child, or is now managing many, many children.
Returning to the Workplace
Jen: Did you hear any intriguing stories when moms went back to work?
Catherine: We asked people, "What are your ideas for improving the breast pump?" and dealing with the "back-to-work" era was one of these key themes that emerged in our analysis. It's a real moment of trauma in a lot of ways. People are making really difficult decisions. And they don't necessarily want to be making those decisions at that point. Not everyone wants to be returning to work. Some do want to return to work, which is fine, but then there's that question of "Where does the baby go?" and the accompanying guilt, the choice of whether or not you're trying to maintain the breastfeeding relationship, the unknowns about your workplace, about your coworkers or your boss, whether you'll have time for breaks to pump.
Jen: Requesting that time.
Catherine: Requesting that time. Having those conversations. There are all of these juncture points where people don't feel supported. And when we're talking about support, it's like: "Where's the family?" But once they're moving back into their professional, outside-of-the-home employment, companies don't necessarily understand, coworkers don't necessarily understand. There's a policy piece but then there's also a cultural piece. We're asking: "How do we normalize and celebrate breastfeeding and breast pumping as being an active, amazing thing?" A body can feed another body entirely—that's kind of amazing. But when you're choosing to either pump or breastfeed or both, you're making a huge sacrifice in a lot of ways. You are spending a lot of time, you are investing a lot. A lot of women, especially women in the workplace, feel shame. You're hidden in some server closet or bathroom with an old mop or something.
Jen: For our project around the future workplace, we looked a lot at how to create ambient environments of calmness. I know, from going through breastfeeding at work, that the pumping room was one of the first and only places where the lights were dimmed. My experiences while traveling were not at all like that. Airplane bathrooms. But in our project, we're thinking about amber lighting, thinking about the colors that are given off by a room, creating that mood is almost so simple it should be done everywhere. I traveled to Japan during the first month I got back after giving birth, and there was so much more consideration for breastfeeding there. So, in a Japanese bathroom, you have a bench with a cushion and whatever you might need. And the lighting is much calmer and dim. It was just fascinating to see the difference.
Catherine: Every time I'm in an airport, I always go into the lactation space, even though I'm not breastfeeding anymore, just to check it out. I'm starting to see them more, too, which is a cool thing, but I feel that many times, they're very typical of an airport bathroom. There's fluorescent lighting…
Jen: There might be a table.
Catherine: There might be a table. There's usually a chair if it's a lactation space, and there's usually a baby-changing station. But they're still pretty bathroom-y. The spaces don't say: "Hey, I want to hang out here."
Jen: They're "greyge" as I call it.
In our research, we found that women often feel medicalized by the breast pump.
Catherine: What is greyge?
Jen: Grey plus beige. Greyge.
Catherine: That's hilarious.
More Than Just "Women's Health"
Jen: One of the things that I find crazy about this space, is that it's lagging behind consumer electronics and traditional medicine design by maybe 10, 15 years. The breast pump should be as elegant as an iPhone. It should be—
Catherine: —as quiet as a Prius.
Jen: Yes. It's amazing to me how the "volume" piece is fundamentally absent in the breast pump space. Especially because I think it's very appreciated in such an intense-use case. I know that when we looked at the Medela design and imagined what Sonata could feel like, it was our intent to get as close to cupping something between your hands, so that you could literally feel like you were lifting and creating this comfort motion without necessarily having to lift it by a handle (even though it has one). And then with the form, the look, and the feel, we tried to create a sophisticated form without it feeling too playful. We were thinking about mom as a woman, as opposed to mom as a mom.
Catherine: In our research, we found that women often feel medicalized by the breast pump. Again, it's the idea of "How could it be more about celebrating this really interesting, extreme, and temporary state of the body?" versus "You have a problem, so you have to carry your medical device around in the bulky greyge medical bag." So I think a lot of people react to the aesthetics, but it's also environmental. A lot of women talked about the space where they pumped, and the sound. Did you guys do anything with the sound?
Jen: Medela led that charge. They were trying to get it as quiet as… they kept using the metaphor of mouse scampers. Basically, quieter than any pump they'd ever designed in the past.
Whenever I'm handed forms that ask "Which of these medical conditions have you had?" and "pregnancy" is one of those, I always respond with a lecture about how pregnancy is not a medical condition.
Jen: Mine just said, "Watch out, watch out."
Catherine: That's so anxiety-inducing.
Jen: Probably because I was stressed, yeah.
Catherine: I think of the postpartum time period as being very open. Your body is open. You just had this whole human that you brought into the world.
Jen: Your mind is open—
Catherine: —and your mind is open, in this really interesting, but sometimes scary way. And it makes for these associations.
Jen: The whole way in which these things are shared, in terms of information and communication, could be very different. I feel like a lot of the time it feels like this: "You're in the hospital, okay, now you'll be introduced to your pump." Or you're at your doctor's office: "Now you'll be introduced to your pump." It would be so fascinating to look at this as a lifestyle brand. To think about how to empower, not just inform.
Catherine: I think that the moment of introduction is so important. Many women talk about how in the hospital they just hear: "Here's your pump. Good luck with that!" The whole title of our research paper is a quote from a mom: "When I first saw a breast pump I thought it was a joke."
Jen: This contraption over here.
Catherine: I think that also goes to your point about how the breast pump has been overlooked. That has also been one of the key things that we've wanted to address in our project. Why have, both this device but also this time period, been so over-looked by medical establishments, in terms of models of care? Why have they been overlooked by the innovation, technology, and product development industries? It's just a space that's been really under-innovated, and it feels like partially just because people have said: "Oh, that's women's health." They've got their medical devices for that weird medical time of their life, and that's what it is.
Whenever I'm handed forms that ask "Which of these medical conditions have you had?" and "pregnancy" is one of those, I always respond with a lecture about how pregnancy is not a medical condition. It is a normal state of the body. I am not pathologically weird.
Jen: Women were only sent to hospitals to have babies in the 1930s. Before that, they were focused on keeping you at home, keeping you in your natural environment, not in a medicalized environment.
Catherine: Which makes a lot of sense, actually. That's what all of the data are showing. In the U.S., we spend more on birth than any other country, and our outcomes are the worst of any industrialized country, in terms of infant and maternal mortality, because we do a lot of interventions that don't necessarily need to happen.
Jen: From what I've found on other projects, birth at a hospital is a loss leader. They're starting to invest in, hopefully, birthing tubs and being baby friendly, but it's at a cost.
Catherine: It's not their priority.
Just like breastmilk is magic, design is magic. Design can touch people in an emotional way that not every book or article or discussion always can.
Now, I have one question to pose to you about equity in innovation. One of the reasons we've framed this event that's coming up around equity is that the first time around, our basic message was: We need to innovate in this space. We felt like we put that out there and we've seen a lot of innovation. The Sonata is part of that. The Willow pump came out. The Naya pump. The Freemie. And we've also seen really exciting stuff happen in women's health around some of these narratives with women owning their bodies—the Thinx brand, Yona Care, they're really cool. They might come to the hackathon, actually. So, we think that's great, but one of the reasons we've focused on equity this time around, meaning specifically racial and socioeconomic equity, is that we want to bring this stuff to everyone. As we make these new products, as we're design new speculums, new breast pumps, new period panties, or whatever other things might be coming down the line, we're thinking: "How do we make those innovations equitable? How do we make them affordable? How do we get them out there more?" That's maybe more than a design question, because it's also structural.
Jen: I think it's about taking innovation to a level of social impact and culture. I love that you're looking at policy change. You're not just looking at the technical piece of the puzzle but thinking about the root of the problem, which is the only way that you can really change the system. What's really fascinating about that is that government doesn't tend to think in an innovative approach, so bringing officials into these things is a great way to start. Innovation, in general, is about building, about testing, about iterating at a fast pace. Innovation relies on creative people coming together, over and over and over again.
What's important, in terms of equity, is to work at a broad scale, by bringing all those people together. Which you are.
Equity in Design: Going Beyond the Breast Pump
Catherine: What do you think the role of designers is in the equity conversation?
Jen: I think, just like breastmilk is magic, design is magic. Design can touch people in an emotional way that not every book or article or discussion always can. So, if you can make a system, an object, a digital experience, whatever it is, speak to people in a way that's emotionally relevant, then you're doing something that can be extremely impactful. I would say design is also universalizing, in that it actually makes all kinds of people want the same thing altogether, which is incredible. So, you could want that thousand-dollar pump. So could the woman on the street. So could I. The amazing thing is that we're very different from very different backgrounds, but good design makes that a worthwhile endeavor and something that a lot of people want together.
Catherine: So, you become the locus of advocacy, in a way, and work to make the better design object an affordable standard that everyone should expect from the world around them. I love this idea.