The AFA Blog

A world on fire.

  by Corey Whelan

It feels like the whole world is on fire right now.  Civil unrest and natural disasters have been nudging the stressometer up notch by notch in our collective unconsciousness for awhile now, I think.  I remember reading newspaper articles years ago about the Cold War and how constant anxiety about the bomb was increasing the daily stress that Americans (and I'm sure Russians too) lived with, like a sort of  low level whirring sound in the brain that you forget is there, but that never really recedes.  

Headlines this weekend about that fool, that monster, that idiot in Florida and the violence that has ensued since he burned the Koran pumped up the jam just enough to flip me out completely.  It just feels like open season now, not just on Americans world wide, but on the whole species Human Being.  As it has always been, I guess.

I thought about all this while I was running this morning.  Three miles in and I started to think about stocking up on bottled water.  Five miles in and I started to think about the talk I need to have with my children about all this and how I don't want to.  Seven miles in and I remembered the reason why I started running in the first place.

Many of you who haven't known me for forever find it hard to believe that once upon a time I weighed around 50 pounds more than I do now.  Pregnancy with multiples, and a marriage that was shredding itself to bits turned into a lust for bagels, maple syrup and low fat dulce la leche frozen yogurt that I deluded myself into thinking was ok for me to eat on a daily basis.  And then 9/11 happened.

My babies were small then.  I remember thinking, if I have to run out of a burning building with one kid under each arm, would I be able to do it?

And the answer was no.  I was too overweight and out of shape to run and get my babies and myself to safety if I ever needed to.

So I went for a walk.  A very long walk.  And a few days later I went for a run.  A very short run.  And I threw out the bagels and all the high carb crap I had let my PCOS insulin resistant body get addicted to and I slowly became my old, healthy-weight self again.  Strong, thin, and robust.  My own personal best for my own physical self.

People, look.  I don't know what's coming next, none of us do.  But I do know that no matter what comes, and also no matter what doesn't come, the species human being, all of us, deserve the right to be our own personal best.  For me it's being a runner who weighs 115 lbs.  For you it may mean being a walker or a tennis player who weighs 135 lbs.  But whatever your own personal health best is, I urge you to acheive it.  It is better for your fertility.  It will be better for your pregnancy and your baby, God willing.  It will be better for you no matter what life brings.  Really.  

Think about maybe joining in and doing what The AFA staff will be doing for NIAW.  Think about doing a Fertility Bootcamp, if that feels like a fit for you.  Think about doing something.  And then just do it.  

I don't know what's coming next.     

Twins are everywhere!

by Jamie Schenk DeWitt

Next time you are walking down the street or jogging in the park, notice how many double or even triple strollers there are.  I was at the park yesterday with my 21-month-old twin daughters and saw three pairs of twin strollers and one set of triplets!  

Based on figures from the American Society for Reproductive Medicine, approximately 30% of couples that undergo ART (Assisted Reproductive Therapy) will give birth to twins versus 1-2 % of spontaneous pregnancies.  

Below are two of the reasons why:

1.  Fertility drugs that are prescribed to patients encourage the ovaries to release more than one egg during ovulation.  

 2. During the embryo transfer of an IVF (In vitro fertilization) cycle, doctors often implant more than one embryo in the womb.  (Ever since the infamous Octomom debacle fertility doctors have been under fire for implanting more than one embryo, but -- needless to say -- depending on the woman’s age,  infertility diagnosis and doctor’s medical evaluation, sometimes it may make sense to implant more than one embryo).  

The first consultation that my husband and I had with our fertility doctor he asked us,   “How do you feel about having twins?”  Spontaneously I responded, “Great!  I would love it.” Our physician went on to inform us that there was a greater chance of having multiples when using assisted reproductive methods.  Because I was so distraught over not being able to get pregnant naturally it seemed like a blessing to get pregnant with one baby, let alone twins.

8 months after our initial visit with our fertility doctor, I was pregnant with twins.  It was one of the most joyous days in my life.  After all of the failed treatments, it felt like a miracle that I was pregnant.  And since being pregnant with twins put me in the high-risk pregnancy category, I was consumed with staying healthy, and the reality of what it meant both physically and financially to take care of twins after they were born did not faze me right away.  Yes, we bought two cribs, two car seats and a double Snap-n-Go stroller (an essential item) in preparation for their arrival.   Yet, the notion that we would have to do two of everything at the same time, -- two diapers, two feedings, and two baths – did not hit me until the morning they were born. Literally, my life changed in an instant. 

The challenges of their first three months, from trying to figure out how to simultaneously breastfeed two babies, to consoling two hysterically crying infants, to learning how to synchronize their schedules, so I could get some sleep at night were tremendous.  I can still remember the first night that I was alone with both of them.  The baby nurse and my mom had left to go back to their respective cities and my husband was working late.  I had successfully positioned both girls on each breast in the football position for their evening feeding.  However, when it came time to give them each a bottle (I had to supplement with formula since I didn’t produce enough milk for two babies) all hell broke out.  They were both crying.   I couldn’t figure out how to hold both of their heads up at the same time to give them their bottles. It was a disaster.  By the time my husband came home, I was bawling.  

Needless to say, I ended up figuring out how to manage that situation, but in the process I felt awful.  It would take several months of trial and error for me to feel like a “mother of twins.” Taking care of my daughters was the most difficult job that I had ever encountered, but with each new challenge that I conquered, I found my voice as a mother.  I learned how to trust myself, rely on the advice of other parents of twins, and use parenting experts in my community.  I also drew incredible strength from observing my spectacular girls grow and develop.  I was proud of who we were becoming as a family and with this newfound confidence, I never shied away from taking them to the park, classes, play dates or the grocery store by myself, which believe me, felt like quite an accomplishment at the time. 

Over the course of the first year I can still clearly remember the comments and looks that I got from other parents or strangers when they would see me out with my twin daughters.  

 “Wow twins!  You’ve got your hands full.”

“Are they twins?  So adorable!”

“Twins!  Two for the price of one.” (If they only knew how much IVF cost)

“A boy and a girl?”

“Are they identical?  Wow, they sure look identical don’t they?”

“You sure have a lot of energy for having two babies.” 

“They must keep you on your toes.”

“Agh twins.” (Insert look of desire) “I wanted twins, but I didn’t get so lucky.  I only have one baby.”

“Agh twins. How’s that going for you?” (Insert look of terror)

“Two babies.  Bet you’re busy.”

“I can’t believe you have twins!”

 Dead silence.  (Insert look at the babies, then look at me. Enough said.)

“Are you enjoying both of them?”

“So precious!”

“Do you have help?”

“Oh my God – Twins!  I could never imagine.”

“She looks so much like you.” (Pointing to the daughter who looks exactly like her father)

“They are so adorable.  You must get sick of hearing that?  They sure must keep you busy?  Okay I’ll leave you alone.”

“A boy and girl?  No.  Two boys.” (One is dressed in purple and the other in hot pink.)

 “You are so lucky and blessed.”

“That’s a lot of work.”

“Do twins run in your family?”

So whether you are taking care of one baby, two or three babies, motherhood is a journey and not a destination. Enjoy the ride because it all goes by so fast!   And just realize that if you need fertility treatments, know if you are willing to have a multiple birth, and know all the facts, both medical, emotional, and practically speaking. 

 Even though we did not plan on having twins when we began our fertility treatments I have learned from my own experience, as well as that of other mother’s of twins that the question of whether or not it is safe to have multiples is one to be taken very seriously. There are tremendous risks to both mother and babies when someone attempts to have a multiple pregnancy and you should make sure that you discuss this in depth with your doctor prior to conception being attempted.. 

 According to the Society for Assisted Reproductive Technology (SART).  the objective of infertility treatment should be the birth of a single, healthy child.  Multiple gestations, meaning twins or greater, can pose significant health concerns.  These include but are not limited to:

• Increased Rates of Miscarriage
• Increased Rates of Fetal Death, Even After Birth
• Cerebral Palsy:
• Increased Levels of Nausea, Heartburn and Vomiting during Pregnancy
• Pre-eclampsia (High Blood Pressure)
• Gestational Diabetes:
• Placenta Previa
• Heart Problems, Including Heart Attack for the Expectant Mother:
• Increased Need for Partial or Complete Bedrest, and Limited Physical Activity:
• Emotional Issues, including the possible need for Mutifetal Reduction
• Increased Rates of Caesarian Section Delivery
• Complications after Birth such as Development Delays or Autism

A sobering, and partial list.  It is important to note that not all twin pregnancies are problematic, many like mine, only posed temporary challenges that we as a family were able to overcome.  The American Fertility Association will be publishing several significant commentaries on this issue during 2011, as well as a fact sheet and video on elective Single Embryo Transfer, later on this month.  In depth information on all aspects of mutliple birth will be covered.

The Amazing Story of the Birth of the “Twiblings”

by Iris Waichler, MSW, LCSW

           For those of you who haven’t read it I strongly encourage you to read Melanie Thernstrom’s New York Times Magazine article called “Meet the Twiblings” at http://www.nytimes.com/2011/01/02/magazine/02babymaking-t.html.

Ms. Therstrom and her husband use an egg donor and 2 different gestational carriers that end up giving birth to twins that are born 5 days apart. I loved this article for many reasons.  She candidly discusses a multitude of issues that will be familiar to many who experience infertility.  Examples include:

1.      Beginning infertility treatment later in life.

2.      Finding a doctor that will show empathy but be honest about your best chance for success in having a healthy baby.

3.      Unscrupulous surrogacy and egg donation agencies.

4.      Legal challenges of surrogacy.

5.      Societal judgements about infertility treatment, surrogacy, and egg donation.

6.      What role do you want your egg donor and surrogate to play in your new family’s life?

We learn about Ms. Thernstrom starting out at age 41 meeting her eventual husband.  She undergoes 6 treatment failures in her attempt to have a baby. Her doctor poses a critical question that changed her life.  He asked “Is your goal to have the experience of being pregnant or is your goal to have the best chance of having a healthy baby?”  I believe that question is not asked often enough by physicians.  It is the primary question those who have had repeated fertility treatment failures need to ask themselves.

This article is filled with valuable information those in the midst of infertility treatment can apply. There is a wonderful description of meeting the 2 women who eventually become her surrogates. Fie, one of the surrogates, goes over the surrogacy agreement line by line and she and Ms. Thernstrom carefully discuss scenarios so they have a clear agreement about how to proceed. They talk about whether the surrogates will provide breast milk after the baby is born? Consider questions you must ask like who pays living costs if your surrogate is unable to work due to the pregnancy?

The surrogate’s husbands were involved and met with the Thernstroms. The role of the surrogate husband is important and is rarely considered.  Their support is invaluable during their wives pregnancy.  Ms. Thernstrom observed her surrogates in their roles as parents and that was a major consideration for her in choosing them.

We learn about Ms. Thernstrom meeting her egg donor.  It was important for her to meet the donor.  Some choose to use an anonymous donor.  She describes looking at the woman who became her egg donor and thinking “When she flashed a smile, I wondered if I had caught my first hint of my child’s grin.”  There is that natural inclination for the perspective mother to make comparisons between herself and her egg donor.  Consider your feelings about that and what role if any you want your egg donor to play in your future child’s life.

The Thernstrom’s speak with the director of their egg donor agency about disclosure. She recommends “tell everyone or tell no one.”  Disclosure is one of the more challenging aspects of infertility.  You need to decide if you want your child to hear directly from you in your own words about their birth.  You may risk your child possibly learning from someone else. How  will that impact your child and your relationship with him/her?

Using a surrogate or an egg donor requires a huge leap of faith. You have to trust that the donor is honest about their medical history.  You want to believe your surrogate will take all the necessary steps you would to be as healthy as possible during the pregnancy.

Ms. Thernstrom coins the phrase “twiblings” to describe her children.  The same egg donor was used and the embryos were transferred the same day. The kids were born 5 days apart from two different gestational carriers. She also uses the word “Fairy Goddonor” to describe her egg donor.  Much like Sarah Palin’s word “refudiate” I hope these words should become an accepted part of English language.

            I thought a lot about this remarkable story. This particular case involved a small “village” of people united together to create a family. I applaud the courage of Ms. Thernstrom for telling her story in such a public forum.  She has gotten both praise and unwelcome comments from friends, professionals and strangers.  I realized that all of us have a unique story to tell about how we become a family. It is our choice how and whether to tell it or not

ASRM 2010: Just Say NO

by Merry Armentrout

ASRM leaders took advantage of this year's gathering in Colorado to sound off about the state's proposed Amendment 62.  If passed, Amendment 62 would give legal rights to fertilized eggs, which means a fertilized egg would have equal rights to a human being.  ASRM held a press conference this morning to state their fervent opposition against Colorado's Personhood Amendment, calling it a "deceptive and dangerous measure." 

ASRM President Dr. William Gibbons started off the press conference by saying the organization represents the doctors who care for the 1 out of 8 couples in the U.S. suffering from infertility, and applying personhood to any human being from the beginning of biological development is denying those infertile couples the solution to help build their families.  ASRM is bringing $12 million to Denver this year, and Gibbons indicated if the amendment was passed it would effect any future decisions to hold this meeting in the state of Colorado.  He went on to acknowledge the irony between this upcoming vote on 62 on November 2nd, and the recent recognition of Robert Edwards, who helped develop IVF, as a Nobel Prize recipient. 

Dr. William Schlaff, a board member for ASRM, focused on the dangers of this amendment on infertility treatments, including embryo transfers.  If an embryo is considered human, than a woman undergoing IVF would have to transfer all her embryos into her uterus- this would be very dangerous for not only the women's health, but also greatly increase the number of multiple births.  Schlaff also talks about an anticipated increase in genetic diseases because an embryologist wouldn't be able to discard abnormal embryos, and would be forced to implant them into the woman's uterus. The decision about which and how many embryos to transfer should remain in the hands of the physician and couple undergoing IVF, and be based on hard scientific evidence. 

Schlaff gives an example from Shady Grove Fertility, the largest U.S. fertility clinic, of the how many embryos could be effected by the passage of this amendment.  From 2005-2008, Shady Grove did 14,500 IVF cycles, producing 200,000 eggs from those cycles.  57% of those eggs were fertilized, and only 7.5% of the fertilized eggs would go on to become children.  He says this amendment isn't about protecting every person, but a direct assault on Colorado's efforts to build families in a safe manner. He goes on to discuss how unused embryos are often donated towards the studies for cures for such diseases Alzheimer's, diabetes and spinal diseases. 

ASRM member Dr. Nanette Santoro spoke about how the personhood amendment could effect family planning and emergency contraception.  She says 43 million sexually active adults in the United States, and of those, 89% are practicing safe sex with the use of birth control pills. There are 2.9 million youths having sex, and 54% of those use birth control pills to prevent pregnancies.  Santoro says the amendment has a far reaching effect on women's health and autonomy.

ASRM, along with The AFA, are urging Colorado residents to vote NO to Amendment 62 on November 2nd.

Scientific Strides With Embryo Transfers

 

by Iris Waichler

I was fascinated by a recent article I read in Time Magazine.  It announced that researchers at Stanford University had discovered they could film embryos developing during the first 2-3 days after they were placed in a Petri dish.  Why is this so important?  Having this information helps embryologists identify “the best embryo to transfer to a woman’s womb.” 

            Ten years ago my husband and I sat in our R.E.’s office. It was our last IVF treatment.  We had decided to stop infertility treatment if this treatment failed.  I had spoken with professionals, people who had experienced infertility treatment, and read everything I could about IVF treatment to prepare for this final attempt. 

            The embryologist popped his head in the room and said, “We have 3 embryos. One of them looks great, one is marginal, and the other doesn’t look so good.” I will give you 5 minutes to decide how many to transfer” and he disappeared.   It was one of the most difficult moments in my years of infertility treatment.  What did it mean when an embryo is described as “marginal”? How could we make a life changing decision with so little information? How dare they put us in this position? I realized all my preparations would not help with this choice.  We decided to go with the amazing looking embryo and leave the others behind.  I was concerned if I became pregnant with one of the other 2 embryos there was a danger of having a child with developmental or medical problems.  Ours was a happy ending with the birth of my healthy daughter. We called her “amazing Grace.”

            The science of observing and understanding embryo development has evolved so people trying to build their families today will have more valuable information than we did when facing our transfer decision.   Researchers have learned what to observe to identify the most “viable embryos.”

 

            1. “The time it took to cleave from a single fertilized egg into two cells.

            2. The time between each of the next two cell-division cycles. (Faster is better)”

 

            Stanford experts say this information offers a “93%” accuracy rate determining which embryos would make it through the next couple of days.  This means transfers can be done as soon as 2 days after the embryo is fertilized.  The Stanford team believes this film technique will improve pregnancy success rates and also reduce the need for multiple transfers resulting in fewer multiple births. 

 Iris Waichler, MSW, LCSW, is a licensed clinical social worker who has counseled people experiencing infertility.  Ms. Waichler is the author of the award winning book “Riding the Infertility Roller Coaster: A Guide to Educate and Inspire”. She currently writes freelance infertility and health related articles.

 

 

Life has a deadline too.

by Corey Whelan

My daughter doesn't pick up after herself.  Those TV shows about hoarders scare the crap out of me because her room looks a little bit like that.  My son is much more meticulous. But sometimes, it's hard for us to find common ground in our conversations, that's just the way it is right now.  And many days, I just get very, very tired. 

On other days I am energized, invigorated, but not by family so much as by my job. I work from home and often when the kids burst in from school, they are bursting in on a very productive but all consuming work day for me, bursting in on my consciousness when what I really want is to be writing, having a relationship with my computer, and not with them.

My IVF twins.

Whom I love.

Wanted.

Struggled to Conceive.

And who sometimes annoy the crap out of me and I wish they'd just go away, for five minutes, ten, just twenty more minutes.

I saw this video today and I sobbed my heart out.  I remembered how desperately I struggled to have these babies, how much I longed for them, how much I bargained with God for them and promised to be The Perfect Mother Always.  I remembered.

I love my babies, now fifteen years old.  I love them, my always babies and I am grateful.  And I wanted to share my honest heart that sometimes?  No matter how much you wanted and loved them and all of the rest of it, sometimes, the mom gig, especially the single mom gig, can truly get to you.  And you just feel tired.  And you know that all of those younger, beautiful women out there who read your words on this page and are currently TTC, will think you're a monster, a brat, a sham for feeling this way.

I wanted to post this today so I would stop myself short the next time my beautiful daughter wants to show me her new aerobics routine and all I can think about is a writing deadline, to remember that life has a deadline too.

I wanted to share this video with you, so that you would remember too.  And for those of you who find that these lyrics rip you to shreds because you are not there yet, remember, you will make it there.  You will make it too.      

Breast feeding - a state by state guide

 

The U.S. Department of Health and Human Services has just issued an updated state by state guide on breastfeeding laws (below).  My own personal opinion is that women should be free to safely nurse their baby(s) anywhere they need to at any time, and that this should not be an issue that needs to be regulated by law; thankfully, the laws in most states are however significantly favorable for nursing moms and babies, this is very good news. I have personally seen women nurse comfortably on New York City subways and in parks, but I have also seen unsuspecting moms harshly removed from tables where meat could not be mixed with milk, or asked to leave restaurants.  I have witnessed people attempt to shame mothers for breastfeeding their babies.  Having nursed my own twins for almost a year, I am a strong advocate that breast is best.  And as a woman who herself conceived through In Vitro Fertilization, I felt that the information given here was important to pass along to the current population of women who are striving to become mommies themselves - Corey Whelan

Breastfeeding Laws

Updated March 2010

Resources

Health professionals and public health officials promote breastfeeding to improve infant health. Both mothers and children benefit from breast milk.  Breast milk contains antibodies that protect infants from bacteria and viruses.  Breastfed children have fewer ear infections, respiratory infections, urinary tract infections and have diarrhea less often.  Infants who are exclusively breastfed tend to need fewer health care visits, prescriptions and hospitalizations resulting in a lower total medical care cost compared to never-breastfed infants.  Breastfeeding also provides long-term preventative effects for the mother, including an earlier return to pre-pregnancy weight and a reduced risk of pre-menopausal breast cancer and osteoporosis. According to the Centers for Disease Control and Prevention, approximately 70 percent of mothers start breastfeeding immediately after birth, but less than 20 percent of those moms are breastfeeding exclusively six months later. It is a national goal to increase the proportion of mothers who breastfeed their babies in the early postpartum period to 75 percent by the year 2010.  

Federal Health Reform and Nursing Mothers

President Obama signed the Patient Protection and Affordable Care Act, H.R. 3590, on March 23rd and the Reconciliation Act of 2010, H.R. 4872, on March 30, 2010. (See the combined full text of Public Laws 111-148 and 111-152 here.)  Among many provisions, Section 4207 of the law amends the Fair Labor Standards Act of 1938 (29 U.S.Code 207) to require an employer to provide reasonable break time for an employee to express breast milk for her nursing child for one year after the child's birth each time such employee has need to express milk.  The employer is not required to compensate an employee receiving reasonable break time for any work time spent for such purpose.  The employer must also provide a place, other than a bathroom, for the employee to express breast milk.  If these requirements impose undue hardship, an employer that employs less than 50 employees is not subject to these requirements.  Furthermore, these requirements shall not preempt a state law that provides greater protections to employees.

State Breastfeeding Laws

• Forty-four states, the District of Columbia and the Virgin Islands have laws with language specifically allowing women to breastfeed in any public or private location (Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Washington, Wisconsin and Wyoming).

• Twenty-eight states, the District of Columbia and the Virgin Islands exempt breastfeeding from public indecency laws (Alaska, Arizona, Arkansas, Florida, Illinois, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Montana, Nevada, New Hampshire, New York, North Carolina, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Virginia, Washington, Wisconsin and Wyoming).

• Twenty-four states, the District of Columbia and Puerto Rico have laws related to breastfeeding in the workplace (Arkansas, California, Colorado, Connecticut, Georgia, Hawaii, Illinois, Indiana, Maine, Minnesota, Mississippi, Montana, New Mexico, New York, North Dakota, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Vermont, Virginia, Washington and Wyoming).

• Twelve states and Puerto Rico exempt breastfeeding mothers from jury duty (California, Idaho, Illinois, Iowa, Kansas, Kentucky, Mississippi, Montana, Nebraska, Oklahoma, Oregon and Virginia).

• Five states and Puerto Rico have implemented or encouraged the development of a breastfeeding awareness education campaign (California, Illinois, Minnesota, Missouri and Vermont).

Several states have unique laws related to breastfeeding. For instance,

• The state of Virginia allows women to breastfeed on any land or property owned by the state.  Puerto Rico requires shopping malls, airports, public service government centers and other select locations to have accessible areas designed for breastfeeding and diaper changing that are not bathrooms.

• At least two states have laws related to child care facilities and breastfeeding.  Louisiana prohibits any child care facility from discriminating against breastfed babies. Mississippi requires licensed child care facilities to provide breastfeeding mothers with a sanitary place that is not a toilet stall to breastfeed their children or express milk, to provide a refrigerator to store expressed milk, to train staff in the safe and proper storage and handling of human milk, and to display breastfeeding promotion information to the clients of the facility.

• California requires the Department of Public Health to develop a training course of hospital policies and recommendations that promote exclusive breastfeeding and specify staff for whom this model training is appropriate.  The recommendation is targeted at hospitals with patients who ranked in the lowest twenty-five percent of the state for exclusive breastfeeding rates.

• Maryland exempts the sale of tangible personal property that is manufactured for the purpose of initiating, supporting or sustaining breastfeeding from the sales and use tax.

• California, New York and Texas have laws related to the procurement, processing, distribution or use of human milk.

• New York created a Breastfeeding Mothers Bill of Rights, which is required to be posted in maternal health care facilities.

First Letter of State A C D F G H I K L M N O P R T U V W 

States	Summary of Statutes
Alabama	Ala. Code § 21-1-13 (2006) allows a mother to breastfeed her child in any public or private location.
American Samoa
Alaska	Alaska Stat. § 29.25.080 and § 01.10.060 (1998) prohibit a municipality from enacting an ordinance that prohibits or restricts a woman breastfeeding a child in a public or private location where the woman and child are otherwise authorized to be. The law clarifies that lewd conduct, lewd touching, immoral conduct, indecent conduct, and similar terms do not include the act of a woman breastfeeding a child in a public or private location where the woman and child are otherwise authorized to be. (SB 297)
Arizona	Ariz. Rev. Stat. Ann § 41-1443 (2006) provides that indecent exposure does not include an act of breastfeeding by a mother and entitles a mother to breastfeed in any public place where the mother is otherwise lawfully present.
Arkansas	Ark. Stat. Ann. § 5-14-112 and § 20-27-2001 (2007) allow a woman to breastfeed in any public or private location where other individuals are present. The law also exempts breastfeeding women from indecent exposure laws.   Ark. Stat. Ann. § 11-5-116 (2009) requires an employer to provide reasonable unpaid break time each day to an employee who needs to express breast milk for her child and requires an employer to make a reasonable effort to provide a private, secure and sanitary room or other location other than a toilet stall where an employee can express her breast milk. (2009 Ark. Acts, Act 621, HB 1552)
California	Cal. Civil Code § 43.3 (1997) allows a mother to breastfeed her child in any location, public or private, except the private home or residence of another, where the mother and the child are otherwise authorized to be present. (AB 157) Cal. Civil Code § 210.5 (2000) allows the mother of a breastfed child to postpone jury duty for one year and specifically eliminates the need for the mother to appear in court to request the postponement. The law also provides that the one-year period may be extended upon written request of the mother. (Chap. 266; AB 1814) Cal. Health and Safety Code § 1647 (1999) declares that the procurement, processing, distribution or use of human milk for the purpose of human consumption is considered to be a rendition of service rather than a sale of human milk. (Chap. 87; AB 532) Cal. Health and Safety Code § 123360 and § 1257.9 require that the Department of Public Health include in its public service campaign the promotion of mothers breastfeeding their infants. The department shall also develop a training course of hospital policies and recommendations that promote exclusive breastfeeding and specify staff for whom this model training is appropriate.  The recommendation is targeted at hospitals with exclusive patient breastfeeding rates ranked in the lowest twenty-five percent of the state. (2007 Chapter 460, SB 22) Cal. Labor Code § 1030 et seq. (2001) provides that employers need to allow a break and provide a room for a mother who desires to express milk in private. Cal. Assembly Concurrent Resolution 155 (1998) encourages the state and employers to support and encourage the practice of breastfeeding by striving to accommodate the needs of employees, and by ensuring that employees are provided with adequate facilities for breastfeeding and expressing milk for their children. The resolution memorializes the governor to declare by executive order that all state employees be provided with adequate facilities for breast feeding and expressing milk.
Colorado	Colo. Rev. Stat. § 25-6-301 and § 25-6-302 (2004) recognize the benefits of breastfeeding and encourage mothers to breastfeed.  The law also allows a mother to breastfeed in any place she has a right to be.  (SB 88) Colo. Rev. Stat. § 8-13.5-101 et seq. (2008) require an employer to provide reasonable break time for an employee to express breast milk for her nursing child for up to two years after the child's birth.  The employer shall make reasonable efforts to provide a place, other than a toilet stall, for the employee to express breast milk in privacy.  The law also requires the Department of Labor and Employment to provide, on its website, information and links to other websites where employers can access information regarding methods to accommodate nursing mothers in the workplace. (2008 Colo., Sess. Laws, Chap. 106, HB 1276)
Connecticut	Conn. Gen. Stat. § 31-40w (2001) requires employers to provide a reasonable amount of time each day to an employee who needs to express breast milk for her infant child and to provide accommodations where an employee can express her milk in private. (HF 5656) Conn. Gen. Stat. § 46a-64 (1997) prohibits places of public accommodation, resort or amusement from restricting or limiting the right of a mother to breastfeed her child. (1997 Conn. Acts, P.A. 210) Conn. Gen. Stat. Ann. § 53-34b provides that no person may restrict or limit the right of a mother to breastfeed her child.
Delaware	Del. Code Ann. tit. 31 § 310 (1997) entitles a mother to breastfeed her child in any location of a place of public accommodation wherein the mother is otherwise permitted. (Vol. 71 Del. Laws, Chap. 10)
District of Columbia	D.C. Code Ann. § 2-1402.81 et seq. amend the Human Rights Act of 1977 to include breastfeeding as part of the definition of discrimination on the basis of sex, to ensure a woman's right to breastfeed her child in any location, public or private, where she has the right to be with her child.  The law provides that breastfeeding is not a violation of indecent exposure laws.  The law also specifies that an employer shall provide reasonable daily unpaid break periods, as required by the employee, so that the employee may express breast milk for her child.  These break periods shall run concurrently with any break periods that may already be provided to the employee.  Requires that an employer make reasonable efforts to provide a sanitary room or other location, other than a bathroom or toilet stall, where an employee can express her breast milk in privacy and security.  The location may include a childcare facility in close proximity to the employee's work location.  (2007 D.C. Stat., Chap. 17-58; B 133)
Florida	Fla. Stat. § 383.015 (1993) allows a mother to breastfeed in any public or private location. (HB 231) Fla. Stat. § 383.016 (1994) authorizes a facility lawfully providing maternity services or newborn infant care to use the designation "baby-friendly" on its promotional materials. The facility must be in compliance with at least eighty percent of the requirements developed by the Department of Health in accordance with UNICEF and World Health Organization baby-friendly hospital initiatives. (SB 1668) Fla. Stat. § 800.02 et seq. and § 827.071 exclude breastfeeding from various sexual offenses, such as lewdness, indecent exposure and sexual conduct.   Fla. Stat. § 847.0135 (5) (d) (2008)  excludes a mother breastfeeding her baby from the offense of lewd or lascivious exhibition using a computer. (2008 Fla. Laws, Chap. 172, SB 1442)
Georgia	Ga. Code § 31-1-9 (1999) states that the breastfeeding of a baby is an important and basic act of nurture which should be encouraged in the interests of maternal and child health and allows a mother to breastfeed her baby in any location where the mother and baby are otherwise authorized to be. (1999 SB 29, Act 304; 2002 SB 221)  Ga. Code § 34-1-6 (1999) allows employers to provide daily unpaid break time for a mother to express breast milk for her infant child. Employers are also required to make a reasonable effort to provide a private location, other than a toilet stall, in close proximity to the workplace for this activity. The employer is not required to provide break time if to do so would unduly disrupt the workplace operations.
Guam
Hawaii	Hawaii Rev. Stat. § 367-3 (1999) requires the Hawaii Civil Rights Commission to collect, assemble and publish data concerning instances of discrimination involving breastfeeding or expressing breast milk in the workplace. The law prohibits employers to forbid an employee from expressing breast milk during any meal period or other break period. (HB 266) Hawaii Rev. Stat. § 378-2 (1999) provides that it is unlawful discriminatory practice for any employer or labor organization to refuse to hire or employ, to bar or discharge from employment, or withhold pay, demote or penalize a lactating employee because an employee breastfeeds or expresses milk at the workplace. (HB 2774) Hawaii Rev. Stat. § 489.21 and § 489-22 provide that it is a discriminatory practice to deny, or attempt to deny, the full and equal enjoyment of the goods, services, facilities, privileges, advantages, and accommodation of a place of public accommodations to a woman because she is breastfeeding a child.
Idaho	Idaho Code § 2-212 (2002) provides that a person who is not disqualified for jury service under § 2-209 may have jury service postponed by the court or the jury commissioner only upon a showing of undue hardship, extreme inconvenience, or public necessity, or upon a showing that the juror is a mother breastfeeding her child. (2002 HB 497)
Illinois	Ill. Rev. Stat. ch. 20 § 2310/55.84 (1997) allows the Department of Public Health to conduct an information campaign for the general public to promote breastfeeding of infants by their mothers. The law allows the department to include the information in a brochure for free distribution to the general public. (Ill. Laws, P.A. 90-244) Ill. Rev. Stat. ch. 705 § 305/10.3 (2005) amends the Jury Act.  Provides that any mother nursing her child shall, upon her request, be excused from jury duty. (Ill. Laws, P.A. 094-0391, SB 517) Ill. Rev. Stat. ch. 720 § 5/11-9 (1995) clarifies that breastfeeding of infants is not an act of public indecency. (SB 190) Ill. Rev. Stat. ch. 740 § 137 (2004) creates the Right to Breastfeed Act.  The law provides that a mother may breastfeed her baby in any location, public or private, where the mother is otherwise authorized to be; a mother who breastfeeds in a place of worship shall follow the appropriate norms within that place of worship. (SB 3211) Ill. Rev. Stat. ch. 820 § 260 (2001) creates the Nursing Mothers in the Workplace Act.  Requires that employers provide reasonable unpaid break time each day to employees who need to express breast milk. The law also requires employers to make reasonable efforts to provide a room or other location, other than a toilet stall, where an employee can express her milk in privacy. (SB 542)
Indiana	Ind. Code § 16-35-6 allows a woman to breastfeed her child anywhere the law allows her to be. (HB 1510) Ind. Code § 5-10-6-2 and § 22-2-14-2 (2008) provide that state and political subdivisions shall provide for reasonable paid breaks for an employee to express breast milk for her infant, make reasonable efforts to provide a room or other location, other than a toilet stall, where the employee can express breast milk in private and make reasonable efforts to provide for a refrigerator to keep breast milk that has been expressed.  The law also provides that employers with more than 25 employees must provide a private location, other than a toilet stall, where an employee can express the employee's breast milk in private and if possible to provide a refrigerator for storing breast milk that has been expressed. (2008 Ind. Acts, P.L. 13, SB 219)
Iowa	Iowa Code § 135.30A (2002) a woman may breastfeed the woman's own child in any public place where the woman's presence is otherwise authorized. Iowa Code § 607A.5 (1994) allows a woman to be excused from jury service if she submits written documentation verifying, to the court's satisfaction, that she is the mother of a breastfed child and is responsible for the daily care of the child.
Kansas	Kan. Stat. Ann. § 43-158 and § 65-1,248 provide that it is the public policy of Kansas that a mother's choice to breastfeed should be supported and encouraged to the greatest extent possible and that a mother may breastfeed in any place she has a right to be.  The law was amended in 2006 to excuse nursing mothers from jury duty (2006 HB 2284).
Kentucky	Ky. Rev. Stat. § 29A.100 (2007) directs judges at all levels of the court to excuse women who are breastfeeding or expressing breast milk from jury service until the child is no longer nursing. (SB 111) Ky. Rev. Stat. § 211-755 (2006) permits a mother to breastfeed her baby or express breast milk in any public or private location. Requires that breastfeeding may not be considered an act of public indecency, indecent exposure, sexual conduct, lewd touching or obscenity. Prohibits a municipality from enacting an ordinance that prohibits or restricts breastfeeding in a public or private place. (SB 106)
Louisiana	La. Rev. Stat. Ann. § 46. 1409 B 5 prohibits any child care facility from discriminating against breastfed babies. (HB 233) La. Rev. Stat. Ann. § 51. 2247.1 (2001) states that a mother may breastfeed her baby in any place of public accommodation, resort, or amusement, and clarifies that breastfeeding is not a violation of law, including obscenity laws. (2001 HB 377) La. House Concurrent Resolution 35 (2002) establishes a joint study of requiring insurance coverage for outpatient lactation support for new mothers. 2008 La. Senate Resolution 110 requests the Department of Health & Hospitals to study and/or consider a provision of providing non-emergency transportation for new mothers to allow them to visit the hospital and bring their breast milk for their babies.
Maine	Me. Rev. Stat. Ann. tit. 5, § 4634 (2001) amends the Maine Human Rights Act to declare that a mother has the right to breastfeed her baby in any location, whether public or private, as long as she is otherwise authorized to be in that location. (Me. Laws, Chap. 206; LD 1396) Me. Rev. Stat. Ann. tit. 26, § 604 (2009) requires an employer to provide adequate unpaid or paid break time to express breast milk for up to 3 years following childbirth. The employer must make reasonable efforts to provide a clean place, other than a bathroom, where an employee may express breast milk in privacy. The employer may not discriminate against an employee who chooses to express breast milk in the workplace. (2009 Me. Laws, Chap. 84, HB 280)
Maryland	Md. Health-General Code Ann. § 20-801 (2003) permits a woman to breastfeed her infant in any public or private place and prohibits anyone from restricting or limiting this right. (SB 223) Md. Tax-General Code Ann. § 11-211 exempts the sale of tangible personal property that is manufactured for the purpose of initiating, supporting or sustaining breastfeeding from the sales and use tax.
Massachusetts	Mass. Gen. Laws Ann. ch. 111 § 221 (2008) allows a mother to breastfeed her child in any public place or establishment or place which is open to and accepts or solicits the patronage of the general public and where the mother and her child may otherwise lawfully be present.  The law also specifies that the act of a mother breastfeeding her child shall not be considered lewd, indecent, immoral or unlawful conduct and provides for a civil action by a mother subjected to a violation of this law. (2008 Mass. Acts, Chap. 466, SB 2438)
Michigan	Mich. Comp. Laws § 41.181, § 67.1aa and § 117.4i et seq. (1994) state that public nudity laws do not apply to a woman breastfeeding a child.
Minnesota	Minn. Stat. Ann. § 145.894 directs the state commissioner of health to develop and implement a public education program promoting the provisions of the Maternal and Child Nutrition Act.  The education programs must include a campaign to promote breastfeeding. Minn. Stat. § 145.905 provides that a mother may breastfeed in any location, public or private, where the mother and child are authorized to be, irrespective of whether the nipple of the mother's breast is uncovered during or incidental to the breastfeeding. Minn. Stat. § 181.939 (1998) requires employers to provide daily unpaid break time for a mother to express breast milk for her infant child. Employers are also required to make a reasonable effort to provide a private location, other than a toilet stall, in close proximity to the workplace for this activity. (SB 2751)  Minn. Stat. Ann. § 617.23 specifies that breastfeeding does not constitute indecent exposure.
Mississippi	Miss. Code Ann. § 13-5-23 (2006) provides that breastfeeding mothers may be excused from serving as jurors. (SB 2419) Miss. Code Ann. § 17-25-7/9 (2006) prohibits any ordinance restricting a woman's right to breastfeed and provides that a mother may breastfeed her child in any location she is otherwise authorized to be. (SB 2419) Miss. Code Ann. § 43-20-31 (2006) requires licensed child care facilities to provide breastfeeding mothers with a sanitary place that is not a toilet stall to breastfeed their children or express milk, to provide a refrigerator to store expressed milk, to train staff in the safe and proper storage and handling of human milk, and to display breastfeeding promotion information to the clients of the facility. Miss. Code Ann. Ch. 1 § 71-1-55 (2006) prohibits against discrimination towards breastfeeding mothers who use lawful break time to express milk. Miss. Code Ann. § 97-29-31 and § 97-35-7et seq. (2006) specifies that a woman breastfeeding may not be considered an act of indecent exposure, disorderly conduct, or disturbance of the public space.
Missouri	Mo. Rev. Stat. § 191.915 (1999) requires hospitals and ambulatory surgical centers to provide new mothers with a breastfeeding consultation or information on breastfeeding, the benefits to the child and information on local breastfeeding support groups. The law requires physicians who provide obstetrical or gynecological consultation to inform patients about the postnatal benefits of breastfeeding. The law requires the Department of Health to provide and distribute written information on breastfeeding and the health benefits to the child. (SB 8) Mo. Rev. Stat. § 191.918 (1999) allows a mother, with as much discretion as possible, to breastfeed her child in any public or private location.
Montana	Mont. Code Ann. § 39-2-215 et seq. specifies that employers must not discriminate against breastfeeding mothers and must encourage and accommodate breastfeeding.  Requires employers to provide daily unpaid break time for a mother to express breast milk for her infant child. Employers are also required to make a reasonable effort to provide a private location, other than a toilet stall, in close proximity to the work place for this activity. Mont. Code Ann. § 50-19-501 (1999) states that the breastfeeding of a child in any location, public or private, where the mother otherwise has a right to be is legal and cannot be considered a nuisance, indecent exposure, sexual conduct, or obscenity. (SB 398) Mont. Code Ann. § 3-15-313 (2009) specifies that the court may excuse a person from jury service upon finding that it would entail undue hardship for the person; an excuse may be granted if the prospective juror is a breastfeeding mother. (2009 Mont. Laws, Chap. 167, HB 372)
Nebraska	Neb. Rev. Stat. §25-1601-4 (2003) states that a nursing mother is excused from jury duty until she is no longer breastfeeding and that the nursing mother must file a qualification form supported by a certificate from her physician requesting exemption. (LB 19)
Nevada	Nev. Rev. Stat. § 201.232, § 201.210, and § 201.220 (1995) state that the breastfeeding of a child in any location, public or private, is not considered a violation of indecent exposure laws. (SB 317)
New Hampshire	N.H. Rev. Stat. Ann. § 132:10-d (1999) state that breastfeeding does not constitute indecent exposure and that limiting or restricting a mother's right to breastfeed is discriminatory. (HB 441)
New Jersey	N.J. Rev. Stat. § 26:4B-4/5 (1997) entitles a mother to breastfeed her baby in any location of a place of public accommodation, resort or amusement wherein the mother is otherwise permitted. Failure to comply with the law may result in a fine.
New Mexico	N.M. Stat. Ann. § 28-20-1 (1999) permits a mother to breastfeed her child in any public or private location where she is otherwise authorized to be. (SB 545) N.M. Stat. Ann. § 28-20-2 (2007) requires employers to provide a clean, private place, not a bathroom, for employees who are breastfeeding to pump.  Also requires that the employee be given breaks to express milk, but does not require that she be paid for this time. 2009 N.M. House Memorial 58 requests the governor's women's health advisory council to convene a task force to study the needs of breastfeeding student-mothers and make recommendations for breastfeeding accommodations in school environments.
New York	N.Y. Civil Rights Law § 79-e (1994) permits a mother to breastfeed her child in any public or private location. (SB 3999) N.Y. Labor Law § 206-c (2007) states that employers must allow breastfeeding mothers reasonable, unpaid break times to express milk and make a reasonable attempt to provide a private location for her to do so.  Prohibits discrimination against breastfeeding mothers. N.Y. Penal Law § 245.01 et seq. excludes breastfeeding of infants from exposure offenses. N.Y. Public Health Law § 2505 provides that the Maternal and Child Health commissioner has the power to adopt regulations and guidelines including, but not limited to donor standards, methods of collection, and standards for storage and distribution of human breast milk. N.Y. Public Health Law § 2505-a creates the Breastfeeding Mothers Bill of Rights and requires it to be posted in a public place in each maternal health care facility. The commissioner must also make the Breastfeeding Mothers Bill of Rights available on the health department's website so that health care facilities and providers may include such rights in a maternity information leaflet. (2009 N.Y. Laws, Chap. 292; AB 789)
North Carolina	N.C. Gen. Stat. § 14-190.9 (1993) states that a woman is allowed to breastfeed in any public or private location, and that she is not in violation of indecent exposure laws. (HB 1143)
North Dakota	N.D. Cent. Code § 12.1-20-12.1 was amended in 2009 by Senate Bill 2344 to exempt the act of a woman discreetly breastfeeding her child from indecent exposure laws. N.D. Cent. Code § 23-12-16 allows a woman to breastfeed her child in any location, public or private, where the woman and child are otherwise authorized to be. (2009 SB 2344) N.D. Cent. Code § 23-12-17 provides that an employer may use the designation “infant friendly” on its promotional materials if the employer adopts specified workplace breastfeeding policies, including scheduling breaks and permitting work patterns that provide time for expression of breast milk; providing a convenient, sanity, safe and private location other than a restroom for expressing breast milk; and a refrigerator in the workplace for the temporary storage of breast milk. The law also directs to the state department of heatlh to establish guidelines for employers concerning workplace breastfeeding and infant friendly designations. (2009 SB 2344)
Ohio	Ohio Rev. Code Ann. § 3781.55 (2005) provides that a mother is entitled to breastfeed her baby in any location of a place of public accommodation wherein the mother is otherwise permitted. (SB 41)
Oklahoma	Okla. Stat. tit. 38, § 28 (2004) exempts mothers who are breastfeeding a baby from jury duty, upon their request. (2004 HB 2102) Okla. Stat. tit. 40, § 435 (2006) requires that an employer provide reasonable unpaid break time each day to an employee who needs to breastfeed or express breast milk for her child.  The law requires the Department of Health to issue periodic reports on breastfeeding rates, complaints received and benefits reported by both working breastfeeding mothers and employers. (HB 2358) Okla. Stat. tit. 63, § 1-234 (2004) allow a mother to breastfeed her child in any location that she is authorized to be and exempts her from the crimes and punishments listed in the penal code of the state of Oklahoma. (HB 2102)
Oregon	Or. Rev. Stat. § 109.001 (1999) allows a woman to breastfeed in a public place. (SB 744) Or. Rev. Stat. § 10.050 (1999) excuses a woman from acting as a juror if the woman is breastfeeding a child. A request from the woman must be made in writing. (SB 1304) Or. Rev. Stat. § 653.075, § 653.077 and § 653.256 (2007) allow women to have unpaid 30-minute breaks during each four-hour shift to breastfeed or pump. Allows certain exemptions for employers. (HB 2372)
Pennsylvania	Pa. Cons. Stat. tit. 35 § 636.1 et seq. (2007) allows mothers to breastfeed in public without penalty. Breastfeeding may not be considered a nuisance, obscenity or indecent exposure under this law. (SB 34)
Puerto Rico	1 L.P.R.A. § 5165 declares August as "Breastfeeding Awareness Month" and the first week of August as "World Breastfeeding Week" in Puerto Rico. 3 L.P.R.A. § 1466 and 29 L.P.R.A. § 478a et seq. provide that breastfeeding mothers have the opportunity to breastfeed their babies for half an hour within the full-time working day for a maximum duration of 12 months. 23 L.P.R.A. § 43-1 directs the Regulations and Permits Administration to adopt regulations, which shall provide that in shopping malls, airports, ports and public service government centers there shall be accessible areas designed for breastfeeding and diaper changing that are not bathrooms. 34 L.P.R.A. § 1735h states that any woman breastfeeding her child under 24 months old and who presents a medical attestation to such fact is exempt from serving as a juror. (2003 SB 397)
Rhode Island	R.I. Gen. Laws § 11-45-2 (1998) specifies that indecent exposure-disorderly conduct laws do not apply to breastfeeding in public. (1998 HB 8103, SB 2319; 2008 R.I. Pub Laws, Chap. 183, SB 2616) R.I. Gen. Laws § 23-13.2-1 (2003) specifies that an employer may provide reasonable unpaid break time each day to an employee who needs to breastfeed or express breast milk for her infant child.  The law requires the department of health to issue periodic reports on breastfeeding rates, complaints received and benefits reported by both working breastfeeding mothers and employers, and provides definitions.  (2003 HB 5507, SB 151; 2008 R.I. Pub. Laws, Chap. 475, HB 7906) R.I. Gen. Laws § 23-13.5-1 and § 23-13.5-2 (2008)   allow a woman to feed her child by bottle or breast in any place open to the public and would allow her a private cause of action for denial of this right. (2008 R.I. Pub. Laws, Chap. 223 and Chap. 308, HB 7467 and SB 2283)
South Carolina	S.C. Code Ann. § 63-5-40 (2005) provides that a woman may breastfeed her child in any location where the mother is authorized to be and that the act of breastfeeding is not considered indecent exposure. (2008 HB 4747)
South Dakota	S.D. Codified Laws Ann. § 22-22-24.1 and § 22-24A-2 (2002) exempt mothers who are breastfeeding from indecency laws.
Tennessee	Tenn. Code Ann. § 68-58-101 et seq. (2006) permits a mother to breastfeed an infant 12 months or younger in any location, public or private, that the mother is authorized to be, and prohibits local governments from criminalizing or restricting breastfeeding.  Specifies that the act of breastfeeding shall not be considered public indecency as defined by § 39-13-511; or nudity, obscene, or sexual conduct as defined in § 39-17-901. (HB 3582) Tenn. Code Ann. § 50-1-305 (1999) requires employers to provide daily unpaid break time for a mother to express breast milk for her infant child. Employers are also required to make a reasonable effort to provide a private location, other than a toilet stall, in close proximity to the workplace for this activity. (SB 1856)
Texas	Tex. Health Code Ann. § 161.071 (2001) requires the Department of Health to establish minimum guidelines for the procurement, processing, distribution, or use of human milk by donor milk banks. (HB 391) Tex. Health Code Ann. § 165.112 (1995) authorizes a woman to breastfeed her child in any location. Tex. Health Code Ann. § 165.003 et seq. provides for the use of a "mother-friendly" designation for businesses who have policies supporting worksite breastfeeding. (HB 340)  The law provides for a worksite breastfeeding demonstration project and requires the Department of Health to develop recommendations supporting worksite breastfeeding. (HB 359)
U.S. Virgin Islands	14 V.I.C. § 1022 specifies that a woman breastfeeding a child in any public or private location where the woman's presence is otherwise authorized does not under any circumstance constitute obscene or indecent conduct.
Utah	Utah Code Ann. § 17-15-25 (1995) states that city and county governing bodies may not inhibit a woman's right to breastfeed in public. Utah Code Ann. § 76-10-1229.5 (1995) states that a breastfeeding woman is not in violation of any obscene or indecent exposure laws. (HB 262)
Vermont	Vt. Stat. Ann. tit. 9, § 4502 (j) (2002) and 2002 Vt. Acts, Act 117 state that breastfeeding should be encouraged in the interest of enhancing maternal, child and family health. The law provides that a mother may breastfeed her child in any place of public accommodation in which the mother and child would otherwise have a legal right to be. The law directs the human rights commission to develop and distribute materials that provide information regarding a woman's legal right to breastfeed her child in a place of public accommodation. (SB 156) Vt. Stat. Ann. tit. 21, § 305 (2008) requires employers to provide reasonable time throughout the day for nursing mothers to express breast milk for three years after the birth of a child.  Also requires employers to make a reasonable accommodation to provide appropriate private space that is not a bathroom stall, and prohibits discrimination against an employee who exercises rights provided under this act. (2008 Vt. Acts, Act 144, HB 641) 2008 Vt. Acts, Act 203 directs the commissioner of health to convene a healthy worksites work group to identify priorities and develop recommendations to enhance collaborative learning and interactive sharing of best practices in worksite wellness and employee health management.  The work group shall examine best practices in Vermont and other states, including strategies to spread the adoption of workplace policies and practices that support breastfeeding for mothers. The commissioner is required to make recommendations in a report on healthy living initiatives to the legislature by January 15, 2009. (HB 887)
Virginia	Va. Code § 2.2-1147.1 (2002) guarantees a woman the right to breastfeed her child on any property owned, leased or controlled by the state. The bill also stipulates that childbirth and related medical conditions specified in the Virginia Human Rights Act include activities of lactation, including breastfeeding and expression of milk by a mother for her child. (HB 1264) Va. Code Ann. § 8.01-341.1 (2005) provides that a mother who is breastfeeding a child may be exempted from jury duty upon her request. The mother need not be "necessarily and personally responsible for a child or children 16 years of age or younger requiring continuous care during normal court hours." (2005 Chap. 195, HB 2708) Va. Code Ann. § 18.2-387 (1994) exempts mothers engaged in breastfeeding from indecent exposure laws. Va. House Joint Resolution 145 (2002) encourages employers to recognize the benefits of breastfeeding and to provide unpaid break time and appropriate space for employees to breastfeed or express milk.
Washington	Wash. Rev. Code § 9A.88.010 (2001) states that the act of breastfeeding or expressing breast milk is not indecent exposure. (HB 1590) Wash. Rev. Code § 43.70.640 (2001) allows any employer, governmental and private, to use the designation of "infant-friendly" on its promotional materials if the employer follows certain requirements. (2001 Wash. Laws, Chap. 88) Wash. Rev. Code § 49.60.30(g) (2009) provides that it is the right of a mother to breastfeed her child in any place of public resort, accommodations, assemblage or amusement. (2009 Wash. Laws, Chap. 164, HB 1596) Wash. Rev. Code § 49.60.215 the law states that it is an unfair practice for any person to discriminate against a mother breastfeeding her child in any place of public resort, accommodations, assemblage or amusement.
West Virginia
Wisconsin	Wis. Stat. § 944.17(3), § 944.20(2) and § 948.10(2) (1995) provide that breastfeeding mothers are not in violation of criminal statutes of indecent or obscene exposure. (AB 154) 2009 Wis. Laws, Act 148 provides that a mother may breastfeed her child in any public or private location where the mother and child are otherwise authorized to be. The law specifies that in such a location, no person may prohibit a mother from breastfeeding her child, direct a mother to move to a different location to breastfeed her child, direct a mother to cover her child or breast while breastfeeding, or otherwise restrict a mother from breastfeeding her child. (2009 AB 57)
Wyoming	Wyo. House Joint Resolution 5 (2003) encourages breastfeeding and recognizes the importance of breastfeeding to maternal and child health. The resolution also commends employers, both in the public and private sectors, who provide accommodations for breastfeeding mothers. Wyo. Stat. § 6-4-201 (2007) exempts breastfeeding mothers from public indecency laws and gives breastfeeding women the right to nurse anyplace that they otherwise have a right to be. (HB 105)

Sources: National Conference of State Legislatures and StateNet
Note: List may not be comprehensive, but is representative of state laws that exist. NCSL appreciates additions and corrections.

Resources

The Economic Benefits of Breastfeeding
NCSL LegisBrief, January 2010

The Benefits of Breastfeeding
This article appeared in the April 2005 edition of NCSL's magazine, State Legislatures.

American Academy of Pediatrics (AAP) : Breastfeeding

                  AAP: New Mother's Guide to Breastfeeding

American Academy of Family Physicians: Promoting and Supporting Breastfeeding

Center for Disease Control and Prevention: Breastfeeding Topics

Breastfeeding Report Card, 2009

Online Data from the Infant Feeding Practices Study II

Guide to Breastfeeding Interventions, 2005

Food and Nutrition Information Center: Breastfeeding

Le Leche League International

March of Dimes: Breastfeeding

Investing in Workplace Breastfeeding Programs and Policies: An Employer's Toolkit
National Business Group on Health, June 2009. 

Office on Women's Health, U.S. Department of Health and Human Services: Breastfeeding

HHS Blueprint for Action on Breastfeeding

Women, Infants, and Children (WIC): Breastfeeding

Photo: PhotoXpress

 

 

 

The New York Times Got it Right. A Doctor’s Responsibility towards the Obese Infertility Patient

by Daniel Shapiro, M.D.

There was a time in the not too distant past when being a heavy kid was a social kiss of death. I personally did not meet a truly obese kid until I went to summer camp for the first time. I remember being a kid in a restaurant with my grandmother while she commented on the handful of obese diners around us. ‘Have you ever!” was her usual scowl. (Grammy needed to lose about 15 herself, and she was neurotically terrified of being obese).

Thirty five years later we have an obesity epidemic on our hands.  Centers for Disease Control estimates that 35% of American youth are currently overweight and 15% are morbidly obese.  Where previous first ladies of the US have made literacy or drug addiction or health care reform their public focus, Michelle Obama has opened a national conversation about our lousy eating habits. Everywhere you look in this county there are lots of heavy people.

I have no desire to persecute or criticize obese people. As a physician though, I cannot help but wonder what happened to us since the 70’s.  Bill Maher blames the high fructose corn syrup in everything. Others blame our sedentary technology addicted culture.  Perhaps it is the fact that high calorie foods are cheap while nutritious foods tend to be more expensive….a byproduct of governmental price supports for corn and other high-carb crops.

Irrespective of the source of the obesity epidemic, The New York Times got it right when they published a front page article on June 5th on the impact of obesity on the safety of pregnancy. Bottom line…fatter mothers have sicker babies and more complicated pregnancies.  The high rate of obesity among inner city women in particular has put a strain on medical care providers who are ill-equipped to adequately care for pregnant women who cannot be easily monitored, ultrasounded, anesthetized or delivered.

There is some irony in all of this with regards to pregnancy of course…..heavy women have more difficulty getting pregnant in the first place.  One of the more common diagnoses, PCOS, is associated with obesity in those afflicted. For many, oral medication is enough to correct the ovulation dysfunction. For many though, the degree of ovulation disturbance is directly related to their obesity. When Clomiphene fails, patients will need injectible drugs to induce ovulation and pregnancy.  Weight loss would help these patients enormously. LOTS of weight loss might even lead to spontaneous ovulation. Barring that, weight reduction will make pregnancy safer and ovulation induction easier.

Many heavy patients will need very high doses of medication to get them to ovulate, which if successful, increases the risk of multiple birth and complicated pregnancy. For injectible drugs, high and low dose regimens carry the same health risk to the mom, but high dose regimens are very expensive.

So let’s talk this through: Heavy women have a harder time getting pregnant. The drug regimens to overcome the barriers to pregnancy are expensive, cumbersome and have some medical risk associated with them.  Whether single or multiple gestation, obese women have more dangerous pregnancies and worse perinatal  outcomes, which have both  exceptional human and financial costs.

This leads to a very uncomfortable quandary. Is it proper to treat morbidly obese patients with fertility medications? Should we insist on weight loss before we treat? If yes, how much weight should a patient lose? If the patient fails to reach a target weight should we treat anyway?

There are no satisfactory answers to these questions, but it is accepted as a standard of care that we need to warn obese patients about the risk of fertility care and subsequent pregnancy. It is also important that health care providers discuss ideal diet and calorie consumption. Requiring a patient to lose weight is a bit trickier, though I know colleagues who do this. Usually these doctors lose these patients faster than patients lose weight.  There is a famous story (famous for our practice anyway) involving my best efforts to get the weight loss message across in a gentle way. I failed and the patient switched to another MD within 24 hours of her initial consult. The new MD was all too willing to treat her with ovulation induction drugs.  The triplet pregnancy that resulted was ultimately OK but the babies and the mom all went through hell before getting to a good place.

Generally speaking, it is the doctor’s responsibility to focus on the risks of IVF or other fertility care procedures when describing the procedure to all patients. For the obese patient  the doctor needs to ‘lay it on thick’ to influence the patient to choose to lose weight before proceeding with care. It is possible on technical grounds to exclude morbidly obese patients if medical tables or equipment for IVF are not rated for the obese but it is very hard to exclude obese patients or set different requirements for them in advance of treatment if they are within a practice’s technical limits.

Daniel Shapiro M.D. practices at Reproductive Biology Associates in Atlanta, and is a frequent contributor to The AFA blog page.

What Kind of Mother Am I?

by Jamie Schenk DeWitt

My husband and I were sitting in our fertility doctor’s office for the first time.  My doctor had just finished discussing my medical history and the protocol for my treatment when he asked, “Are you okay with the possibility of having multiples? “

Without hesitating I said, “YES!  I would love to have twins.” My husband was silent.  He looked at me and then at my doctor who looked at him and smiled.  A minute later, my husband spoke. ”We never really discussed the reality of having twins, but (he looks over at me) it looks like we are okay with it.”  My doctor responded, “I always ask couples because you know there is a 20- 40 percent chance that it can happen when using assisted reproductive methods.”

I wanted to have a baby more than anything else in the world and if that meant having more than one baby at a time, then great.  At the time, I didn’t think about what kind of mother I would be to a baby or babies.  I just knew like all of us who have gone through fertility treatments that I wanted to be a mother.  Who would put themselves through all the poking, prodding and exposure of their most “private parts’ if they didn’t want to be a mother?

 

Eight months after that meeting with our fertility doctor and after numerous attempts and heartaches, I was pregnant and elated.  During my six-week ultrasound, my husband and I saw and heard the baby’s heartbeat.  We were mesmerized.  We couldn't take our eyes off the screen.  Our doctor then said, “Well, do you want to go fishing for some more?”  We laughed.  Oh, did we laugh and then with a slight move to the right of the ultrasound wand there was another baby’s heartbeat thump, thump, thumping away.  I was one of those 20-40 percent and I WAS PREGNANT WITH TWINS!  I laughed and cried while my husband smiled and fell back against the wall, and said, “There aren’t anymore are there?’  My doctor laughed and said, “No.” 

 

For the next eight months through the nausea and leg cramps, I was the happiest pregnant woman on the planet.  After having traveled to the depths of despair fearing that I couldn’t have children, being pregnant with twins brought me more joy than I had ever experienced in my life.  And thankfully I had a very healthy and easy pregnancy with no complications.

 

At around nine months, just a few weeks before I was going to deliver, the reality of what was happening to me hit with full force.  I was about to be a mother of two babies.  In a few weeks, I would be coming home with two babies who needed the same care at the same time.  This created within me an overwhelming sense of concern.  Could I manage?  Would I be a good mother?   Unable to answer any of these questions, I refocused my energy on believing in myself in the same way that I did when I was going through fertility treatments.  It takes an incredible amount of inner strength to preserver trying to get pregnant and so I tapped back into that will and belief and didn’t let my fear take over.

On April 8, 2009 after thirty-eight and half weeks of being pregnant, Olivia and Charlotte came into the world.  They were two healthy and beautiful little girls.  Olivia weighed 4 pounds 13 ounces and Charlotte weighed 5 pounds 4 ounces.  I immediately started breastfeeding them and thankfully they both latched on quickly and easily.  I listened to the advice of the lactation consultants at the hospital who recommended that since I was feeding two babies and had had a breast reduction that it would be a good idea to breastfeed and supplement with a little formula.  All babies after they are born lose half of their birth weight, so it was very important to my husband and I to keep the girls from losing too much weight.  We agreed that it was okay to supplement with formula as long as we were also breastfeeding.  

 

By day two in the hospital, we were getting into a routine with Olivia and Charlotte and I slowly understood the intricacies of breastfeeding.  Both of the girls were eating well and I felt more confident about my ability to feed them. As a new mother, this was one of my main concerns.  I just wanted them to get what they needed.  

 

By the last feeding of that second night, Charlotte had breastfed and drank her ounce of formula but Olivia only wanted to breastfeed.  I tried and tried to give her the formula, but she didn’t want it.  After several failed attempts, I realized that she was full and when she was hungry, she would eat again.   Sadly, the nurse on call that night felt differently.  When she came into the room and saw that Olivia had not drank the formula, she accused me of trying not to give it to her.  When I explained what had happened, she got very forceful and indignant.  She said, “Well if you aren’t going to give it to her, then I will. “ She actually tried to lean over and take Olivia from me.  My husband quickly stepped in and said, “We would like for you to leave the room please. Now.”  

 

Fifteen minutes after the nurse left our room there was a knock on our door and in walked the pediatrician on call.  He introduced himself and said, “Your nurse just called me and was concerned that…”  I cut him off before he could finish his thought. I said,  "She was concerned that we weren’t feeding our baby.  That we were starving her?”  The doctor continued. “Well, yes.  You know there are those types of women who breastfeed and can be so adamant about…”  Again, I cut him off. I didn’t want to hear his generalizations about women who breastfeed as being radical or dangerous and that they would rather starve their infants than give them formula.  I said, “These are IVF babies.  Do you really think that after what we went through to have these two beautiful babies I would seriously put their lives at risk?  Do you really think that as their mother I would do that?”  

 

In a matter of seconds I was transformed into this lioness protecting and defending her babies. The doctor, realizing my fury with his line of questioning said,  “Oh, no, no.  I didn’t know you had them using IVF.  I totally understand.”  My husband and I just looked at him.  The doctor continued, “I am so sorry.”

 

After the doctor left the room, I sensed that this interaction with him and the nurse was a defining moment in my development as a mother.  For at this vulnerable time, I could have felt bullied into believing that I had no idea how to feed my child.  Instead, I trusted my instincts and found the inner strength to believe that I knew how to take care of her.  From the bottom of my heart, I knew that after everything that my husband and I had experienced to have these babies that we would never jeopardize their health.  The notion was unfathomable.  I would do whatever it took to properly care for them.  That night, I had my daughter’s best interest at heart.  I wasn’t being foolish or selfish.  She wasn’t hungry even though I had tried to give her more. When I stopped trying, it was because I was meeting her needs.  I knew it as her mother.  

For more information on breastfeeding multiples after infertility, click here

When is the Right Time for hCG?

by Fred Licciardi, M.D.

The time between the hCG and retrieval

For an FSH injection cycle leading to insemination, it’s ok if the ovulation naturally occurs a little early (via a premature LH surge) because we can just do the insemination early. Rarely it’s too early, before the follicle is big enough, and we cancel the cycle. However, for an IVF cycle we have to cancel the cycle if there is an early natural LH surge, even if it’s only a little early, because the timing of the retrieval is very dependent on when the surge starts. The retrieval needs to be about 34-36 hours past the start of the surge (which would also be the time if the hCG shot).

Because we are not taking blood every hour, if the blood test shows a rise in the LH level, we don’t really know when the rise started so we don’t know the right time for retrieval. Lupron, Antagon and Cetrotide prevent the natural rise of the LH, so the premature surge usually cannot occur. However, these drugs do not interfere with the effects of an hCG injection. So there is no natural surge, but there is an artificial surge which starts the moment the hCG goes in.

Final Maturation
There is a second very important job of the LH Surge/hCG injection:
it causes the egg to mature. As the days of stimulation progress the eggs are slowly maturing, but more is needed for the final maturation. Necessary last minute changes occur inside the egg from the LH/ hCG.

Why is this important? An immature egg will not fertilize. If the retrieval is before about 33 hours after the hCG, the result will be immature eggs. Sometimes they are all immature, or just some.

If the retrieval is 38-39 hours after the hCG, the eggs will be mature but they will already have ovulated. We would retrieve none; they would be floating in the pelvis around the ovaries waiting to get picked up by the tubes. So we need to grab the eggs just after they mature but just before they ovulate, which is at about 34-37 hours after the hCG injection.

What day should you get your hCG?
hCG can only mature eggs that have been growing for enough time for the follicle to become large. The sizes of all of the follicles need to be taken into consideration before giving hCG in IVF cycle.

Not all of the follicles grow at the same rate. For example, if there are 10 follicles, and the biggest is 18mm, they will not all be 18 mm. Some will be mid-sized and some will be much smaller. Each follicle does not need to be 18 mm to produce an egg that is mature. As long as the biggest (the lead follicle) is 17-18mm, the mid-sized (13-16) should also have mature eggs. The small follicles (10-12) may or not be mature. But if the lead follicle is 14 mm, none of the eggs have yet reached maturity. Giving hCG would not be enough to achieve maturity.

How Important are Estrogen Levels?
Not very. When you are monitored for your IVF cycle, the follicle size is much more important that the estrogen (estradiol) levels. We need the estrogen to rise, but if midway through your cycle we see 10 follicles, with the biggest being 13 mm, we don’t really care if the estrogen level is 500 or 900. Estrogen is more important when we are monitoring someone who may be on track for hyperstimulation.

Therefore, we use mostly the size of the follicles, with not much emphasis on the estradiol levels, to determine when to give the hCG. At NYU we feel the best time to get the hCG is when the lead follicle reaches 18 mm. Now because there are many variations from cycle to cycle and from patient to patient, it’s not easy to say that 18 mm is the rule.

For example, let’s say there is one follicle 18 mm, three that are 15 mm and others that are smaller. Here we may worry that some of the small ones may be too immature, so we may wait another day before giving the hCG. Let’s say there are 20 follicles, with the biggest 17mm and an estrogen level of 2900. Here we are aware that the smaller follicles may be immature, but we also are concerned about the estradiol getting much higher because the woman would be increasing her risk of hyperstimulation. So we give the hCG at 17 mm, which may yield some immature eggs, but should give us enough mature eggs to work with.

And there are many more variations. Some women have gotten their hCG a little on the early side and have all mature eggs. Some women in their first cycle get the hCG at 18 mm with lots of good size follicles, and have ½ their eggs be immature. So next cycle we wait till the follicles are 20-22 mm before giving hCG. This sometimes gets more mature eggs but sometimes no matter what we do, that woman’s ovaries make more immature eggs than expected.

So why not wait and give hCG later? Because eggs can get over-mature. This over-maturity can lead to lower embryo quality and lower pregnancy rates.

When we see the records of women who have failed IVF elsewhere, many times we see that he hCG was given with large sized follicles. The first and easiest “fix” we can do is to give the hCG earlier in her next cycle, more inline with our standard procedures.

Why do some doctors wait longer to give the hCG?
Some may feel that the higher the estradiol level the better, so by waiting estrogen levels will go up. This is probably not important. Others may feel that it is necessary to wait so there will be no immature eggs. Well this sounds good, but it may not be worth sacrificing the quality of the eggs form larger follicles, which are probably the best eggs anyway.

And back to the original question.
What if instead of the average 11-12 days it takes to grow the follicles, they are of the right size after only 6 days or 8 days?
If the size is good, but it seems early, we usually go at least one more day that we normally would, maybe 2. If it’s day 9 and the follicles are 19-20 mm, it really sounds ok to give hCG. If it’s day 7 (so 5-6 days of FSH injections), and the follicles are 17-18 mm, more time would probably be a good idea.