Category Archives: Postpartum period

A New PMAD Handout

When we last revised Pregnancy, Childbirth and the Newborn, I struggled with including the list of all the risk factors for PMAD. It’s important information to have, and yet, I worry about someone who has a lot of those factors reading through it and getting more and more discouraged, and worried that there was no way they could avoid PMAD given their complex history. I wanted to find an approach that could empower rather than defeat.

Yesterday, I played around with a lot of metaphors…

  • a seesaw where the more risk factors you have, the more protective factors you need to balance them out
  • a budget metaphor
  • a fill the bucket metaphor where the risk factors drain the bucket
  • a floating object metaphor… if you have a lot weighing you down, you need a lot to buoy you up so you don’t feel like you’re drowning

Finally I found a metaphor I liked… I created a handout where I try out the baggage metaphor…. if you know you have a lot to carry, then you can plan ahead (pack it well), build your strength (by learning coping skills), get a luggage cart (learn about resources) and ask for help to carry it.

Here’s the free printable handout, feel free to use it any time, anywhere.

I also updated two other handouts: One on what you really need to buy for babies, and one on planning with your parenting partners how you’ll divide up responsibilities after the baby is born.

Newborn Cues Video

The TL; DR: Expectant parents often wonder how they’ll know what their babies need, and new parents often wonder why their baby is crying and what they could do to figure out their needs before they cry. Newborn cues are instinctive behaviors that babies display which help us to figure out what they need. This YouTube video (which you are welcome to share in classes or in one-on-one appointments, or link to from your website) provides an overview of newborn cues. (Here’s a link you can share:

The Story Behind the Video

As a first-time parent back in 1993, I was clueless.. it seemed like my baby would go from 0 to 60 from happy to miserable in a moment. Years later, I watched videos of his early days, and saw that he was giving SO MANY cues about his needs that I missed until he escalated to screaming. So, when I started teaching newborn care classes in ’99, I always incorporated information about newborn cues.

Back in 2010, I put together some YouTube clips as a “Name that Cue” activity to use in my classes. I put it on YouTube for my ease, and in case anyone else would find it helpful. Now that video, and excerpts from it and updates of it have been viewed over 2 million times!

The video linked above is the newest version, where I’ve incorporated feedback I’ve gotten on previous versions and added a couple more clips. I’ve also set it up so it will be easy to create translations of it into other languages, and I’m currently recruiting educators whose native language is something other than English to help me create translations. (contact me at janelled at if you’re interested in helping!)

No Narration Option for Classes

For birth educators or others who are using this video in an educational setting: That video is designed to be watched independent of a class or educator. It’s 20 minutes, which is a lot of time for a class. If you prefer, I have a 13 minute version here with no narration that you can show and talk through it with your students.

Video Segments – Cue by Cue

In 2014, I created segments that covered only one set of cues at a time. Here’s links to those, if you prefer them.

Teaching about Cues

In my podcast episode on Caring for Your Newborn, you can see how I integrate teaching about cues into the information I give on newborn care and feeding.

Setting Expectations for Parenthood

In a journal article on “Mother’s Expectations of Parenthood“, authors Lazarus and Rossouw address the influence of unreasonable prenatal expectations of parenthood on the development of postpartum mood disorders. They make recommendations for antenatal classes that I think are worth consideration for childbirth educators:

“Current antenatal classes focus mainly on the birthing process; however… it is the transition that occurs once the mother is at home that is pivotal in the development of depression, anxiety, stress, and low-self esteem… An education program focusing on compromised infant, support, and self-expectations during the first year post birth should be created and incorporated into existing antenatal classes… This type of education program should perhaps emphasize the potential realities of having a child (such as a difficult and painful birthing experience or a baby with a more difficult temperament) but, most importantly, it should normalize the ambivalence and doubt that a mother may experience post birth, and stress the importance of reaching out for help and talking to others if she experiences even the smallest difficulty during the transition to becoming a new mother.

“This education program could also highlight how current social norms for new mothers as “super mums” is… not merely unattainable but rather it creates an environment that promotes the development of depression in new mothers, given that women feel strongly obliged to isolate themselves and conceal their true feelings when they are experiencing difficulties and/or depression post birth. These behaviors only succeed in further feeding the symptoms of depression by avoiding the issues at hand… If a healthy shift to new motherhood is to transpire, it is the rule rather than the exception that this transition may be accompanied by some degree of grief and loss and changes in mood.”

As a childbirth educator, or doula, do you encourage your clients to think about their expectations and be certain that they are realistic?

In my post on “Failing to Meet Your Own Expectations“, I offer some questions parents can ask themselves about their expectations for their parenting, and some ways to re-frame them to be sure they are attainable goals.

Support and Sanity Savers Handout

I’ve created so many resources over the years that I sometimes forget about some. I got an email today reminding me about this one I wrote back in 2003, with two other educators (Tawnya Ostrer and Jamie Olson)… I looked back and, you know, it’s pretty good! So, I updated it, and will share it here.

This is a handout to be used in a childbirth education class or with doula clients, which encourages expectant parents to plan ahead for practical support, emotional support, and peer support. It also includes a letter that they can give to friends or family members who ask how they can help.

Postpartum Support and Sanity Savers – PDF

Postpartum Support and Sanity Savers – Word (you are welcome to edit the document to substitute your local resources for the Seattle area resources I list. Otherwise, please use as written, with copyright info intact.)

And here’s a related handout to help them plan for a division of labor after birth: Baby Care Plan

Partner and Family Support for Breastfeeding

Today, I did a presentation on Partner and Family Support for Breastfeeding. Here’s a brief re-cap – and be sure to check out the handout linked from the bottom of the page!!

Research on how Partners and Family Members influence choices about whether to initiate breastfeeding and how long the baby is breastfed

  • 2/3 of women have decided before pregnancy that they plan to breastfeed due to the influence of family, friends, health care providers and the media.
  • 1/3 make the decision during pregnancy, and their strongest influences are: 1) care providers, 2) partners, 3) books and classes, 4) other key friends / family.
  • A few months down the road when making decisions about how long to breastfeed, their partner, family and friends are much stronger influences than professionals
  • An expectant parent is more likely to decide to breastfeed and to continue nursing if she believes that key people in her life are supportive of breastfeeding.
  • The presence of a partner / father increases chance she will initiate BF. But if he then gets very involved in day-to-day baby care, her BF duration can actually go down, because he ends up taking over some of the feeds.
  • Having an involved grandma sadly reduces the duration of breastfeeding, and can reduce initiation, especially if grandma didn’t breastfeed herself.
  • However, research shows we can turn this around. If we engage in conversations with partners, and offer written materials targeted at partners and family and classes for them (especially peer led classes) which focus on the importance of breastfeeding, then it is more likely that she will initiate and continue breastfeeding.
  • If those conversations / classes / materials ALSO include information telling the partner or family member that they play a huge role in her choices about breastfeeding, it is more likely she will initiate and continue.
  • If those conversations / classes / materials ALSO give concrete ideas to the partner or family member about how to help support the breastfeeding relationship, she will nurse and nurse for even longer.

To read a whole powerpoint on the evidence surrounding influences on breastfeeding (and how we can influence them), click here  Influence Of Family On BF Choices.

Teaching Partners and Family Members how to effectively support a nursing parent to increase duration of breastfeeding:

Here are five key areas we can focus on:

  • Increase Knowledge: Offer relevant, targeted, accessible info about the process of breastfeeding, with an emphasis on how to help with BF and concrete information about how to prevent, recognize, and treat BF challenges.
  • Enhance Positive Attitude: Teach them all the benefits of BF – for baby, mom, the family, and the world. The more excited they are about breastfeeding, the harder they’ll work to make it happen. Openly and honestly address worries. Encourage family commitment to BF.
  • Involve Them in Decision Making: Welcome their questions and input. Encourage them to help the breastfeeding parent do research and strategize.
  • Encourage Practical Support: Teach them all the skills to care for everything baby needs (other than feeding) and to take care of baby’s things (pack diaper bag, do laundry, etc.). Encourage them to take care of the breastfeeding parent (feeding the mom so she can feed the baby), maintain the house (groceries, cleaning, cooking), and manage outside duties (pay bills, plan, make appointments, etc.)
  • Encourage Emotional Support: Acknowledge partner’s emotional challenges. Encourage them to offer the breastfeeding parent their presence, appreciation, encouragement, affection.

To read a full powerpoint fleshing out these 5 key areas of breastfeeding support, click here: Teaching Family Support for Breastfeeding

Handout You Can Use:

One of the key points in much of the research is that nobody talks to partners about breastfeeding, and that it helps a lot if they are given targeted information that focuses on what the partner needs to know about: benefits of breastfeeding, how it works, how they can help if there are breastfeeding problems and how they can help in general. So, I’ve designed a handout for partners. It is yours to use, free of charge. You can print it, copy and distribute to partners. You can give clients links to it. Anything to help get partners the information they need to be effective supporters of the breastfeeding relationship.

Here’s the PDF of the color version, and here’s the black and white version .


Seeding and Feeding a Baby’s Microbiome

What is the microbiome?

The collection of bacteria, viruses, fungi, and other organisms that live in and on the body. We have about 10 trillion human cells in our bodies, and about 100 trillion microbes. We have evolved in tandem with this microbiome for thousands of years. The balance of microbiomes varies throughout our body, and the bacteria found in our mouths is different than on our skin, which is different than in our intestines.

Why does the microbiome matter?

  • A balance of microbes leads to optimal health. An imbalance can lead to disease. For example, a vaginal yeast infection may occur when the healthy bacteria are reduced by antibiotics, allowing yeast to overgrow.
  • Good bacteria can aid digestion, provide vitamins (K and B12), regulate the bowels, stimulate the development of the immune system, and protect against infection.
  • An overgrowth of harmful bacteria can lead to infectious disease.
  • Disruption of the gut microbiota has been linked to inflammatory bowel disease, diabetes, obesity, allergies, asthma, and some cancers.
  • Many studies have shown that the presence of absence of specific microbes can cause life-long changes in immunity.

How does a baby’s microbiome develop?

  • During pregnancy
    • In the past, the womb was believed to be a sterile environment. However, microbes are found in the placenta, amniotic fluid, and in meconium. (The waste that accumulates in the fetal bowels.)
    • Maternal fecal microbes have been found in the uterine environment, leading to hypotheses that microbes from throughout the body are transferred through the bloodstream. And from there into the placenta, then the umbilical cord and the amniotic fluid.
    • Placental microbes are similar to the microbes in the mother’s mouth – especially types of bacteria that aid in the metabolism of food.
    • Healthy bacteria may benefit baby. For example, if the mother lived or worked on a farm, that might protect against allergies and asthma.
    • Others worry that unhealthy bacteria may affect baby. For example, obese women tend to have abnormal gut microbiota. This may be transferred to the baby.
    • Maternal diet affects the baby. E. coli bacteria (an unhealthy bacteria) was less common amongst babies whose mothers ate primarily organic foods.
  • At birth
    • During a vaginal birth, a baby is exposed to the microbes in mother’s vagina. In the third trimester, these are especially high in lactobacilli, which help the baby to digest milk.
    • When a baby is placed skin-to-skin on a parent, they are exposed to the parent’s skin microbiome. The baby’s skin, mouth, and digestive tract are “seeded” by whatever and whomever they first have contact with.
  • Through feeding
    • Breastmilk exposes the baby to more microbes. Several are gut microbes that influence digestion.
    • Breastmilk contains sugars (oligosaccharides) which are not digestible by babies, and whose role appears to be to nourish / feed a healthy microbiome in baby’s gut. These are also referred to as prebiotics. By helping healthy bacteria to grow, there is less room for unhealthy bacteria.
    • When solid food is introduced, the microbiome begins to evolve to a more adult-like combination of microbes.
  • Through the environment
    • As baby is held by various people, their microbiomes influence it.
    • As the baby starts to explore his world, crawling on the floor, playing outdoors, petting animals, and putting everything in his mouth, his microbiome shifts and evolves, becoming quite diverse by age 3. The “hygiene hypothesis” states that babies who are exposed to more symbiotic organisms have lower risks of asthma and allergies, and stronger immune systems.

What can interfere with the establishment of a healthy microbiome?

  • During pregnancy and labor
    • Antibiotics given to mom can affect the mix of microbes in the placenta, amniotic fluid and vagina. This disrupted microbiome is inherited by the baby.
  • At birth
    • Babies born by cesarean, and thus not exposed to vaginal bacteria, are at increased risk of asthma, allergies, obesity, diabetes, and celiac disease. Studies comparing the microbiomes of vaginally born babies with those born via cesarean have shown differences in their gut bacteria as much as seven years after delivery. (Salminen)
    • After cesarean birth, instead of skin-to-skin contact with the parents, the baby’s first exposures are to hospital bacteria and the bacteria of hospital staff. (Babies in NICU were found to be colonized by bacteria from the health care staff, from medical equipment, and from the counter-tops in the NICU. – Brooks)
  • Newborn care
    • After any birth, if baby is wrapped in a blanket, and placed on a clothed parent, rather than skin-to-skin, the transfer of skin microbes is not complete.
    • Early baths remove / reduce protective vernix, vaginal microbiome, and baby’s own newly seeded skin microbiome. Those are replaced by hospital microbes.
    • If baby is given antibiotics, it reduces microbial diversity, and the number of both harmful and helpful bacteria. The impact lasts over 8 weeks. The longer the duration of antibiotics, the harder it is for the microbiome to recover. Early use of antibiotics, or prolonged use, can have long-term side effects, increasing risk of obesity or inflammatory bowel disease in later life.
  • Feeding
    • Formula-fed babies (even those who just had short-term formula feeding in the first few days) had increased harmful bacteria and decreased helpful bacteria.

What can parents and health care providers do to foster a healthy microbiome?

  • During pregnancy:
    • A mother can increase exposure to diverse healthy bacteria. Taking probiotic supplements may improve gut diversity (for mom and baby), may reduce gestational diabetes, and may reduce risk of allergy and eczema for the baby. (Research cited in Collado) You can eat probiotic foods which introduce healthy bacteria, such as fermented foods and foods with live cultures. And you can eat prebiotics – foods with oligosaccharides which feed healthy bacteria – see the list at the end of this article. (Reed)
    • Minimize exposure to unhealthy bacteria, such as food-borne illnesses.
  • During pregnancy and labor: Minimize exposure to antibiotics. If they are needed, consider consuming probiotics or prebiotics after the course of antibiotics is complete.
  • If baby will be delivered by cesarean, a baby’s initial seeding is from hospital bacteria and skin microbes rather than vaginal microbes. You can expose the baby to vaginal bacteria by swabbing. Although swabbing does not colonize the baby as well as vaginal birth, it helps. (Swabbed babies had twice as much maternal bacteria as babies who were born by cesarean but not swabbed. Babies who were born vaginally had six times as much maternal bacteria.) Here’s the process:
    • Sample mom’s vagina: make sure the mother is HIV-negative, strep-B negative, and has an acid, lactobacillus-dominated vagina.
    • Place sterile gauze in the mother’s vagina. Incubate gauze for one hour. Remove prior to surgery.
    • After birth, wipe baby’s mouth, face and hands with the gauze.
    • Note: If the caregiver will not do this procedure, the mother and partner can do it themselves.
  • After birth, baby should go straight onto the mother’s body, skin-to-skin. (Consider bringing a blanket from home to cover baby, rather than using a hospital blanket.)
  • In the first hours, encourage people other than the parents to look but not touch.
  • Wait 24 hours after birth to bathe the baby.
  • Feed baby only breastmilk for as long as possible.
  • If a breastfeeding mother develops mastitis or a yeast infection, ask a lactation consultant about treatment with lactobacillus probiotics.
  • Giving probiotics to a baby can treat antibiotic-induced diarrhea, prevent eczema, reduce colic symptoms, and possibly reduce obesity in later life. (Studies cited in Arrieta and Collado.)
  • Let your child explore their world, with plenty of time outdoors, digging in gardens, and exposure to animals, both pets and animals at petting zoos.
  • Offer your child diverse foods, including: fermented foods and foods with live cultures (Yogurt, buttermilk, sour cream, kefir, sauerkraut and other fermented vegetables, tempeh, miso, soy sauce, kimchi, dosas and sourdough breads, kombucha, etc.) and prebiotic foods that are high in oligosaccharides (onions, garlic, legumes,  asparagus, starchy vegetables like sweet potatoes, squash, turnips, parsnips, beets, and plantains)

Note: While many of those recommendations are supported by scientific research, not all have been adequately researched.

Here is a 2 page handout of this information to share with clients.


To learn more about practically any topic related to the perinatal period, check out Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Handouts on Sleep and Hormones

I just put up copies of two handouts you may find helpful in your work.

My handout on Hormones of Pregnancy, Labor and Postpartum was written for prenatal yoga instructors and has tips for how they may use this info in their work. But the content about hormones is relevant for anyone.

Another handout covers Infant Sleep from 0 – 6 months. A collection of tips on what to expect for typical sleep patterns and what parents can do to help baby sleep.

Resource for Choosing Child Care



In the past, I have offered these links for students wanting more information on choosing a child care: Child Care Aware of America. They have great articles on choosing child care, and also a state-by-state list of: agencies that do referrals, child care licensing regulations, inspection reports, resources for children with special needs, and more. A fabulous resource! This is Child Care Resources, based in Washington state. They have lots of good info on making the choice, but some of their info (like about their referral line) is only relevant for Washington residents.

I have given, but that URL no longer works. At, you can find their Questions to Ask a Prospective Daycare. The questions are great in many ways, but I find the overall tone could be a little scary for new parents as it talks a fair amount about what can go wrong in child care.

I’m now adding this to my resources: – The National Association for the Education of Young Children. They have great resources on choosing child care (see the infographic at the top of the post). I like that they divide off sections on quality care for infants, toddlers, and preschoolers, because although you’re looking for many of the same things, there are also differences in what counts as quality child care for a 3 month old and a 3 year old. They also have a directory to search for NAEYC accredited child care centers and preschools.

And, for those who are using / will be using a family member to provide child care, here’s a couple good articles on setting clear expectations and resolving conflicts: Should you hire a family member for childcare, and When Family Members are your Child’s Caregiver.

Talking about Prenatal Mood Disorders in Birth classes

pregnancydepressionMost childbirth educators are covering postpartum depression in their classes. Some are also covering other postpartum mood disorders such as anxiety and obsessive compulsive disorder which are quite common. (Depression affects 10 – 20% of new moms, Anxiety or panic disorder affects ~10% and OCD affects 3 – 5%). And hopefully they’re also pointing out that a person can experience multiple disorders at once – for example, she can have depression AND anxiety.

A few educators are remembering to include partners – about 5% of new dads have a postpartum mood disorder.

But I wonder how many of us are talking about mood disorders in pregnancy?

Incidence of Mood Disorders in Pregnancy

Of women who experience depression after birth, a third say it started during pregnancy. (Source) Sometimes, depression is missed because symptoms can be mistaken for the fatigue or appetite disturbances associated with pregnancy. Estimates of incidence of depression in pregnancy range:

Rates determined by structured interview have ranged from 2 to 21% and up to 38% for women of low SES. Estimates derived from self-report questionnaires have ranged from 8 to 31% and 20 to 51%, respectively. Source.

Almost one third of women with manic depression (aka Bipolar disorder) report onset during pregnancy. OCD often begins in pregnancy (pre-existing OCD is usually exacerbated by pregnancy). Interestingly, pre-existing anxiety / panic disorder  may actually decrease in pregnancy due to hormonal effects. Source

How do we talk about this in childbirth classes?

I see multiple places we could address this:

1) when talking about discomforts of pregnancy and the physical changes of pregnancy, you could also address emotional changes and challenges

2) when discussing self-care in pregnancy, could include emotional self care and talk about mood disorders there

3) when talking about postpartum mood disorders.

I find it works well for me to cover it when talking about postpartum mood disorders.When I’m almost done with that topic I say “Although you may hear a lot of talk these days about postpartum mood disorders, we know that they begin in pregnancy for a third of the women who experience them. If you were just listening to my description of symptoms and thinking ‘I feel that way now’, then you may be experiencing a prenatal mood disorder. All the resources for support and techniques for self care I just talked about can also help with pregnancy mood disorders. I would encourage you to reach out for support now – the sooner someone gets support, the sooner they start feeling better. If you have concerns or questions, you can talk to me after class or by email.”

So, it works well for me to cover it near the end of the series when I’m talking postpartum. But, I could also make an argument that it would be better to cover it as early in the series as possible so that parents who are experiencing it get support as early as possible.

When do you (could you) cover it in your classes?

For more resources on perinatal mood disorders, see
photo credit: Maria & Michal P. via photopin cc

Breast Cancer Screening Guidelines

If you just want a brief summary of guidelines, look here. For all the details, read on!

Breast Cancer Screening

Over recent years, there have been significant changes in recommendations for how to screen for breast cancer, how often, what age to start at, and what age to stop screening. A significant influence on the debate has been the recommendations issued by the United States Preventive Services Task Force (USPSTF) in 2009, which are summarized in the chart below. (Read the full document here. Our Bodies Ourselves has a helpful detailed examination of them here.)

Here is a review of current thoughts.

Methods of screening:

  • Breast self-exam (BSE) – Looking in the mirror for changes, then using a standardized pattern to methodically check the breast for lumps or other changes. (Instructions here.) Past recommendations were for monthly BSE, but research hasn’t shown much benefit to this routine, so it is no longer specifically recommended. Instead, they recommend breast self-awareness – this simply means being familiar with your breasts, and having a sense of what is normal for you so you can tell if there are any changes.
  • Clinical breast exam (CBE) – A health care professional examines your breasts, first looking at them for any abnormalities in size or shape, then using hands to feel the breasts, checking for lumps. CDC says it does not reduce the risk of dying from breast cancer
  • Mammograms – An x-ray of the breast. See details here. 70% of women over 40 have mammograms. (NY Times, 2013) It is the most effective method for finding breast cancer (though it has limitations as discussed below) and is recommended for all women, although recommendations range on frequency and on age to begin screening (See below)
  • Magnetic Resonance Imaging (MRI) – magnets and radio waves create detailed, cross-sectional image of the breast. Details here. It is recommended only for high risk women, and only in conjunction with mammograms. (See below.)

Incidence of Breast Cancer

About 230,000 women are diagnosed with breast cancer each year in the United States. That’s 14% of all cancer diagnoses. The chance that a woman will have breast cancer at some point in her life is around 12%, or 1 in 8 chance. Approximately 90% of breast cancer patients survive at least 5 years beyond diagnosis. (SEER)

The risk of breast increases with age. For a 30 year old, the chance she’ll have it in the next ten years is just .44% (1 in 227). For a 70 year old, the chance is 3.82% (1 in 26.) (National Cancer Institute)

Benefits of breast cancer screening:

Breast self-awareness and CBE may detect some tumors. Mammograms can find malignant tumors that could not be detected by hand. Screening can help to detect breast cancers when they are small and more treatable, and before they spread to other parts of the body. A small tumor is easier to remove and less likely to result in mastectomy. Dr. Richard C. Wender, chief of cancer control for the American Cancer Society says mammography reduces the death rate by at least 15% for women in their 40s and at least 20% for older women.

Another way of viewing this is: For an individual woman in her 40s, the chance of dying of breast cancer in the next ten years is .35% if she doesn’t have annual mammograms and .3% if she does. For a woman in her 50s, annual mammograms lower her risk from .53% to .46%. (NY Times, 2013)

For some women, regular screenings can also reduce their anxiety about developing breast cancer. Everywhere women go, they see pink ribbons, and messages that build their fear of breast cancer and reassure them that “mammograms save lives.” So, the annual checkup soothes their fears. (Interestingly, women may be overly fearful of breast cancer. The actual risk of having breast cancer in your lifetime is 12 – 13%. 89% of women overestimate that, with an average estimate of 46%. Science Daily.)

Hazards of breast cancer screening:

  • False negatives: Mammograms may miss 20% of tumors (National Cancer Institute). False negatives are more common for younger women, because mammograms are less effective on younger women’s breasts, which have denser tissue. Digital mammograms may be more effective for women under 50.
  • False positives: the mammogram may find something that after further testing turns out to not be cancer. False positives are more common for younger women, women with a family history of breast cancer, and women who are taking estrogen.
  • Additional testing and procedures: 10% of mammograms lead to follow-up testing. 8 – 10% of those women will get biopsies. (org) “Research has shown that as many as 75% of post-mammogram biopsy results turn out to be benign (non-cancerous) lesions.” (OBOS) In addition to the risks and costs of these biopsies, they put a huge emotional strain on the women involved as they go through a great deal of fear and anxiety through the testing, biopsy, and waiting for results.
  • Over-diagnosis / Over-treatment: Screenings may find DCIS (ductal carcinoma in situ – a non-invasive tumor, which can evolve into cancer) or slow-growing cancers that would never have caused symptoms or threatened the woman’s life. If these are treated, then the woman may be unnecessarily exposed to the side effects of cancer treatment.
    • A recent Canadian study found 22% of the breast cancers detected by screening were over-diagnosed. “Put simply, this means that one in five cancers do not pose a deadly threat, yet these women may still undergo treatment, including surgery, chemotherapy and radiation.” (OBOS)
    • A review concluded that “for every 2,000 women screened annually over 10 years, one life is prolonged but 10 healthy women are given diagnoses of breast cancer and unnecessarily treated, with therapies that themselves have life-threatening side effects.” (NY Times, 2013)
  • Cost: Although most private insurances and Medicare cover the majority of costs of mammogram, and thus individual consumers don’t pay much, the cost to society is high. About 38 million mammograms were performed in the US last year. (FDA) Average cost of a mammogram is $266. (Source.)

Benefit-Risk Ratio depends on the Age and Risk Status of the Individual Woman

The chance of getting breast cancer increases as we get older. The median age of diagnosis is 61. The median age of death is 68. So, screening in your 60s is much more likely to be worth doing (i.e. more likely to find a cancer that will benefit from treatment) than screening at a younger age. The chance of a 20 year woman getting breast cancer in the next ten years is only about .06%. (NY Times, 2013) So, screening is your 20s is not worth doing. (Even talking about breast cancer and breast self-exams with teenagers may just create fear and anxiety without giving benefit.)

What’s the tipping point for starting screening where benefits of screening outweigh the risks? And, what’s talked about less: at what age is it no longer relevant to screen for breast cancer? Let’s start with the recommendations for older women and work down.

Over 75 years of age: Screening may detect breast cancer. But the breast cancers women tend to get at this age are slow-growing. The older woman is more likely to die of other conditions before breast cancer would kill her. Treating a cancer at this age would cause risks and complications and not significantly lengthen life span. USPSTF

Age 50 – 75: There is general consensus that the benefits of screening outweigh the concerns.

Under 50: This is where the controversy lies.

For women who do have breast cancer, mammography increases the chance that will be found early and treated. The USPSTF says screening this age group led to a 15 percent decrease in mortality. The chairman of the USPSTF says: “If I take 1000 women over age 40, over their lifetimes, 30 will die from breast cancer if we do no screening. If I screen every one of those women beginning at age 50 until she’s 74, we reduce the deaths from 30 to 23.” He says if we start the screening in their forties, we might increase that by one additional life saved. (i.e. 22 would die)

However, the rate of false positives and over-treatment are higher for younger women. “Starting mammograms at 40 would mean having exams every two years for an average of 34 years. Over a lifetime, a woman’s chances of needing a biopsy to prove she didn’t have breast cancer might be as high as 50 percent.” (OBOS)

“The Cancer Society says for every 1,000 women in their 40s screened for 10 years, 600 will be called back for a repeat mammogram for something suspicious, 350 will get biopsied and about five will end up with a diagnosis of breast cancer. And some women might get treated for a cancer that would never have caused a problem.”

Most experts say that between 40 and 50, the decision whether or not to screen is best made through a shared decision-making process between a woman and her physician / caregiver where they evaluate her risk factors, discuss the benefits and risks of screening, and assess her personal feelings about the screening – would it reduce her anxiety or increase it? For women at higher risk of breast cancer (see below), caregivers are more likely to recommend screening in their 40s (or, rarely, even younger than 40) versus they may recommend waiting until your 50s if you are at low risk.

Screening Recommendations

Here is my comparison of major recommendations, from: The Susan Komen Foundation, American Cancer Society (ACS), American Congress of Obstetricians and Gynecologists (ACOG), and the United States Preventive Services Task Force (USPSTF).


* Breast Self Awareness and BSE: What to Look For

Women should be familiar with their breasts and, on occasion, check their appearance in a mirror and/o touch them to see if there are any unexplained changes. Women should remember that breast changes occur with pregnancy, breastfeeding, aging, menopause, during menstrual cycles, and when taking birth control pills or other hormones. It is normal for breasts to feel a little lumpy.

The Komen Foundation and American Cancer Society recommend that if you see these changes, check with your care provider:

  • Development of a lump – a thick hard knot inside the breast or under the arm
  • Swelling, warmth, redness, or skin irritation
  • Change in the size or shape of the breast; nipple pulling inward
  • Dimpling or puckering of the skin
  • Nipple discharge (other than breastmilk) that starts suddenly

** Risk Assessment

MRI recommendations say that it should be done in addition to mammogram, not instead of, and should be done only for women at high risk: those whose lifetime risk of breast cancer is 20 – 25% or higher.

Here are some guidelines from ACS and Komen Society on what factors would be assessed to determine high risk: A known BRCA1 or BRCA2 gene mutation or a first degree relative with one. Strong family history of breast cancer at age 45 or younger. A personal history of invasive breast cancer, DCIS, LCIS, or atypical hyperplasia. Radiation therapy to the chest between 10 and 30 years of age, Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndromes.

How have benefits, risks, and survival rates changed over the years?

It is difficult to compare studies of how women have fared over the past 25 years with how they will fare over the next 25 years. Here are some factors that have changed breast cancer survival rates:

  • Awareness: Decades ago, breast cancer was not often spoken of. Women might have had lumps or other breast changes that they did not report to a physician until too late. As our society has talked about it more and more, it has raised awareness of the issue, which makes it more likely that women with concerning changes will seek treatment sooner.
  • Incidence: Increased screening has increased the number of cancers found. (i.e. the percentage of women who will receive a breast cancer diagnosis in their lifetime)
  • Understanding of breast cancer: We used to believe that most or all breast cancer was aggressive and would spread throughout the body if not detected and treated early. We now know there are several types of cancer found in the breast (NY Times, 2013), some of which are very slow growing or non-invasive, and some will disappear on their own. (NY Times, 2014) Thus, some of those extra diagnoses mentioned in the previous bullet point are likely to be of cancers that would never have developed into anything clinically significant.
  • Treatment has improved: There has been a 25% reduction in deaths since 1990, but it’s likely that is due to treatment, not to detection. (NY Times, 2013), Reductions in mortality are “more likely explained by changes in risk factors and improved treatment than by screening mammography.” BMJ.

Fear of Cancer, and the Politics and Economics of Breast Cancer Screening

Beyond the medical research and current guidelines, there are interesting cultural issues related to this topic which affect recommendations and affect whether women follow those recommendations.

What was the political response to the USPSTF guidelines?

“Rather than engaging in discussion about how to maximize the benefits of screening while minimizing its harms, Republicans seized on the panel’s recommendations as an attempt at health care rationing. The Obama administration was accused of indifference to the lives of America’s mothers, daughters, sisters and wives. Secretary Kathleen Sebelius of the Department of Health and Human Services immediately backpedaled, issuing a statement that the administration’s policies on screening “remain unchanged.” (NY Times, 2013)

How Do Women Feel about Screening Starting at Age 40?

After the USPSTF released their recommendations in 2009, a USA Today survey found that 76% of women disagreed with the recommendations. 84% of women age 35 – 49 said they would get a mammogram before age 50. 76% of women believed the panel recommended fewer mammograms because of cost, even though the panel only looked at medical benefits and risks.

The survey also showed again that women overestimate their risk of breast cancer. Whereas a 40-year-old woman’s chance of getting breast cancer in the next decade is only 1.4%, 40% of women think the chance is 20 – 50%.

Prophylactic mastectomy

Of women who have been diagnosed with cancer in one breast, there has been a significant increase in those opting for a double mastectomy. One study says they chose this to prevent having to face a second cancer (98%) and to improve chance of survival (94%). Even among women diagnosed with DCIS (a risk factor for cancer), there was a 188% increase from 1998 – 2005 in women choosing double mastectomy.

For women with a genetic predisposition to cancer, removing both breasts does not necessarily improve survival rates, and they were generally aware of that when making the decision.

For women who do not have a genetic predisposition, the chance of a cancer in the other breast is only 2 – 4 %, but those women tended to believe that the chance was 10%. In another study they estimated it at 30%. So, they may be basing their decision to have a double mastectomy on a fear-based over-estimation of the risk.

(Data combined from these sources: and NY Times 2013.)

Breast Cancer Charities may benefit from fears of breast cancer

A Susan Komen Foundation ad campaign from 2011 said “The 5-year survival rate for breast cancer when caught early is 98 percent. When it’s not? 23 percent.” Dr. Steven Woloshin from Dartmouth says this implies “[mammography] has this huge effect, and you’d have to be really irresponsible or crazy to not be screened.” (Huffington Post) But, Woloshin says the statistics are deceptive: “a woman in her 50s who goes for regular mammograms for 10 years will only cut her chance of dying by a fraction of a percentage point — for every 10,000 women who are screened 7 deaths will be prevented.” (MedicineNet)

Gayle Sulik, a sociologist, credits Komen (and other charities) for raising awareness of the disease, transforming “victims” into “survivors” and distributing over $1 billion to research and support. But she says “the function of pink-ribbon culture — and Komen in particular — has become less about eradication of breast cancer than self-perpetuation: maintaining the visibility of the disease and keeping the funds rolling in.” The Komen Foundation does have some vested interest in keeping awareness of breast cancer high. (NY Times, 2013) In 2012, CNBC reported that Komen’s annual income was around $340 million, and that Komen’s founder and CEO received an annual salary of $684,000, which is about a quarter million dollars higher than what is typical for a charity of that size.

Does anyone else have a vested interest in annual mammograms?

“[An] editorial in BMJ, “Too Much Mammography notes that it is difficult to make changes around screening mammography practices “because governments, research funders, scientists, and medical practitioners may have vested interests in continuing activities that are well established.” (OBOS) For example, the American College of Radiology, a trade organization for professionals who conduct and interpret mammograms, objected to recommendations to do mammograms less frequently.

Reducing your Risk of Breast Cancer

Obviously, no matter what screening approach you choose, we’re all hoping the results come back negative! What are some things you can do to increase that chance?

  • The more months of total breastfeeding in your life, the lower your risk.
  • Limit alcohol. No more than one drink a day.
  • Control your weight. Obesity, especially after menopause, increases your risk.
  • Don’t smoke. Smoking especially increases the risk of premenopausal breast cancer.
  • Limit hormone therapy for menopause related concerns. If you use, try the lowest possible dose that relieves your symptoms, keep use short-term (less than 3 years).
  • Minimize exposure to radiation and environmental toxins.
  • Exercise regularly.