The scene is a familiar one in many Indian households, where the boundaries of the home are often porous but the boundaries of the body are carefully guarded. A six-month-old girl is being bathed - a scientist in a diaper, her movements simple and uninhibited. Her two-year-old brother wanders through the open door, observing her with the same neutral curiosity he might afford a passing stray cat or a new toy.

Immediately, the air in the room thickens.

An auntie’s voice intervenes, sharp and reflexive.

“Don’t let him watch.”

As a pediatrician, I recognize this as a clinical non-event. To the toddler, watching is a synonym for learning. His gaze carries no adult meaning, only curiosity. Yet, as a parent and a cultural observer, I feel the weight of that intervention. It is the first brick laid in the architecture of modesty.

The moment raises a question that extends far beyond one bathroom in one home:

Who teaches children that bodies are private? And at what point does a necessary lesson in privacy become a lesson in shame?

The Biological Baseline: Children Are Not Born Embarrassed

From a clinical perspective, children enter the world as biological beings long before they become social beings. Infants explore everything available to them - their hands, feet, ears, mouths, and eventually their genitals. Certain sensations feel pleasant. Certain discoveries hold their attention. This is not sexuality in the adult sense; it is curiosity, sensation, and self-discovery.

Psychologists describe pleasurable physical sensations as unconditioned positive experiences. Children do not initially attach moral meaning to them. Those meanings are learned later through interactions with the adults around them.

This is where culture enters the story.

When a child touches a genital area and is redirected calmly, one lesson may be learned. When the same behavior is met with disgust, panic, or punishment, a different lesson may emerge. Repeated reactions of anger, embarrassment, or alarm can teach children to associate parts of their bodies with anxiety. The body itself has not changed. The meaning attached to it has.

Children are not born embarrassed by their bodies. They gradually learn what their culture considers private, acceptable, inappropriate, or shameful.

The Developmental Trajectory: From Curiosity to Privacy

As children move from toddlerhood into middle childhood, their relationship with their bodies changes.

Studies examining normative childhood sexual behaviors consistently show that public body exploration, games such as “doctor,” and casual undressing become less common with age. At the same time, a different pattern emerges: children begin seeking privacy.

The most interesting developmental story is not what disappears but what appears.

While public touching declines, shyness about undressing increases. Children who once streaked through the house unclothed begin closing bathroom doors. They become more aware of themselves as social beings viewed by other people.

Modesty appears to emerge through an interaction between developmental changes and social learning. Children become increasingly aware of themselves, while culture teaches them what should be hidden, when, and from whom.

In my practice, I often reassure parents that “doctor” play is usually a normal part of preschool curiosity. Young children are, in essence, amateur scientists. They notice differences. They compare. They ask questions. Novelty itself is rewarding.

What concerns clinicians is not curiosity but asymmetry: coercion, force, distress, secrecy, significant age differences, or behaviors that persist despite redirection.

The challenge for adults is distinguishing ordinary curiosity from situations that genuinely warrant concern.

The Indian Context: Modesty, Honor, and the Reflex of Harm

Perhaps the most striking feature of that bathroom scene is not the children’s behavior but the adults’ certainty.

Nobody pauses to ask whether a two-year-old understands what he is supposedly being protected from. The rule feels self-evident.

Yet if we trace it backwards, we often arrive not at evidence but at inheritance.

Someone once taught us that brothers and sisters should not see each other naked.

Someone taught them.

And someone taught them before that.

Cultural norms often survive not because they are explained, but because they are repeated.

In many Indian homes, modesty is taught long before it is explained.

A girl may be told to pull down her frock before she understands why.

A boy may be removed from a room before anyone can articulate what danger they are trying to prevent.

The lesson arrives first. The rationale comes years later, if at all.

This does not make the lesson wrong. Every society develops rules around bodies, privacy, and boundaries. The question is what those rules are trying to achieve.

In many Indian families, concepts such as maryada, propriety, respectability, and family honour shape the way boundaries are taught. Adults often intervene reflexively because they perceive boundaries as protective. The concern is not necessarily the children in front of them, but the social and moral framework they hope the children will eventually inhabit.

Contrast this with cultures that normalize communal bathing, family saunas, or greater comfort with non-sexual nudity. These societies are not necessarily less protective of children. Rather, they define risk differently.

Both approaches are attempts to answer the same question:

How do we teach children respect for bodies and boundaries?

The answers differ because cultures differ in what they perceive as threatening.

Clinical Insights: The Barriers of Innocence

In the pediatric office, one of the greatest barriers to healthy communication is often adult discomfort.

There is a persistent fear that explaining bodies somehow encourages behavior. Yet children are already learning. The question is whether they learn from trusted adults or from confusion, secrecy, and half-truths.

I think of the mother who, after her young son noticed menstrual blood in the toilet, explained that she had simply eaten beetroot.

It was a harmless lie. It was also a missed opportunity.

The body, in that moment, became something to explain away rather than understand.

Parents often delay conversations because they fear exposing children to information too early. Yet children are remarkably capable of accepting simple biological explanations when offered calmly and without embarrassment.

The lesson they remember is often not the explanation itself but the emotional tone surrounding it.

Children are observers before they are moralists.

They watch our faces. They watch our discomfort. They watch what topics cause us to lower our voices.

And from those observations, they begin constructing their own understanding of what bodies mean.

The Language of Respect: Consent and Autonomy

If we want to build an architecture of safety rather than an architecture of shame, the foundation is autonomy.

Children need to learn not that bodies are embarrassing, but that bodies belong to them.

This begins with language. A child who knows proper anatomical words is often better equipped to describe symptoms, ask questions, or report a boundary violation. Naming a body part does not remove innocence; it removes secrecy.

It continues through everyday interactions.

When we respect a child’s refusal to hug a relative, we teach bodily autonomy.

When we offer alternatives instead of insisting on physical affection, we teach consent.

When we explain that some body parts are private—not because they are dirty, but because they belong to the child—we teach boundaries.

These small moments build something larger: a child who understands that respect for their own body and respect for other people’s bodies are inseparable.

Returning to the Bath

At that bathroom threshold, the two-year-old is exactly what he appears to be: a curious child doing what curious children do.

His baby sister has no concept of modesty.

He has no concept of a gendered gaze.

The adults in the room see a boy and a girl.

The children see a brother and a sister.

Our task as parents and clinicians is not to eliminate innocence prematurely nor to preserve it indefinitely. It is to guide children as they gradually move from curiosity toward privacy, from dependence toward autonomy.

Bodies are ordinary.

Bodies are personal.

Bodies deserve respect.

Perhaps the most important challenge is teaching all three truths at the same time.

Part 4 of a 4-part series on maternity leave and workplace realities

Over the last three pieces in this series, we have spoken about:

• the pressure to return early

• the gap between policy and lived reality

• and why many women quietly leave months after returning to work

But not every mother has the option of delaying her return.

Many women go back because:

• financially, they need to

• professionally, they want to

• or practically, they have no real alternative

So perhaps the more important question is this:

What actually helps women sustain work after returning?

Not just survive the first few weeks.

But build a life that feels workable over time.

Share Your Friendly Neighbourhood Paediatrician

First: We Need to Stop Treating Return as a Single Event

Returning to work after childbirth is often treated like a milestone:

• She rejoined

• She resumed duties

• She’s back

But in reality, return is not an event.
It is a transition phase that may last many months.
And when systems expect mothers to function exactly as they did before childbirth within days or weeks of returning, the strain becomes inevitable.

What Helps Mothers Sustain Work?

There is no single solution.

Because sustainability depends on multiple layers of support working together:

• personal

• family

• workplace

• societal

And when any one layer collapses, the burden often shifts silently onto the mother.

1. Realistic Expectations Matter More Than Motivational Advice

One of the most harmful messages new mothers receive is:

“You can do it all.”

Because technically, many women do. But at enormous personal cost.
The goal should not be proving limitless capacity.
It should be building a rhythm that is physically and emotionally sustainable.

That may mean:

• reduced productivity temporarily

• changing routines

• lowering non-essential expectations

• accepting help without guilt

• recognising that efficiency and wellbeing are not always aligned

2. Lactation Support Needs to Be Treated as Infrastructure

For breastfeeding mothers, return-to-work planning often revolves around logistics no one speaks about openly:

• where to pump

• when to pump

• how milk will be stored

• whether meetings can be interrupted

• whether travel is manageable

• how painful engorgement may become if schedules fail

These are not “minor inconveniences.”

They directly affect:

• maternal comfort

• breastfeeding continuation

• mental wellbeing

• and work performance itself

A workplace that supports lactation practically - not symbolically - can significantly change a mother’s experience of returning.

3. Flexible Work Only Helps If Workloads Are Also Flexible

Remote work and hybrid systems have helped many families.
But flexibility is meaningful only if expectations evolve alongside it.
Otherwise, mothers simply end up:

• working professionally

• parenting simultaneously

• and never fully switching off from either role

True flexibility includes:

• realistic deadlines

• predictable scheduling

• fewer unnecessary meetings

• autonomy over work hours where possible

• understanding that caregiving interruptions are normal, not exceptional

4. Childcare Is Not a Personal Problem Alone

One of the biggest myths around working motherhood is that childcare is an “individual family issue.”

In reality, childcare infrastructure shapes workforce participation directly.

Reliable childcare changes everything:

• punctuality

• concentration

• mental load

• career continuity

• breastfeeding sustainability

• and parental wellbeing

And yet, many mothers return to workplaces where:

• crèche access is absent

• daycare timings clash with work schedules

• backup systems are fragile

• childcare illness disrupts entire weeks

We often speak about women “dropping out” of the workforce without acknowledging how structurally difficult we make staying in it.

5. Managers Matter More Than Policies Sometimes

Two women can work in the same organisation under the same maternity policy - and have completely different experiences.

Often, the difference is the immediate supervisor.

Managers who make an enormous difference are often the ones who:

• normalise honest conversations

• avoid penalising temporary flexibility

• recognise invisible caregiving labour

• allow phased reintegration

• focus on long-term retention rather than short-term optics

Supportive leadership is not about lowering standards. It is about understanding that sustainable performance requires sustainable systems.

6. Fathers and Families Matter Too

The conversation around working motherhood often centres entirely on women.

But sustainability improves dramatically when caregiving becomes genuinely shared.

That includes:

• fathers taking active responsibility

• families supporting rather than policing mothers

• workplaces normalising caregiving for men too

Because as long as childcare remains culturally coded as “primarily the mother’s responsibility,” the imbalance persists regardless of policy.

7. We Need to Stop Framing Survival Choices as Failure

Some mothers continue exclusive breastfeeding after returning to work.

Some partially breastfeed.

Some transition to formula earlier than planned.

Some reduce work responsibilities.

Some step back temporarily from career progression.

None of these decisions happen in a vacuum.

And many are shaped less by preference than by available support.

What matters is not whether motherhood looks ideal from the outside.

What matters is whether the system allows women to remain physically well, emotionally functional, and professionally present without constant collapse.

What Sustainable Support Actually Looks Like

Sustainable support is not:

• one wellness webinar

• one congratulatory bouquet

• one “welcome back” email

It is a workplace and social structure that recognises:

the postpartum transition does not end at six weeks, or even six months.

Real support looks like:

• adequate leave

• functional childcare

• lactation infrastructure

• realistic expectations

• flexible career pathways

• and cultures where mothers do not feel quietly punished for caregiving

The Question We Should Leave With

Perhaps the goal should not simply be getting women back to work as quickly as possible. Perhaps the goal should be helping women build working lives they can sustainably remain in.

Because when mothers leave the workforce, it is rarely because they suddenly lost ambition.

More often, it is because the cost of staying became too high.

And systems that genuinely support mothers do not just improve maternal wellbeing.

They build healthier families, stronger workplaces, and more sustainable societies.

Part 3 of a 4-part series on maternity leave and workplace realities

When we talk about maternity leave and return-to-work challenges, most conversations focus on the early weeks.

• The first day back

• The logistics

• The childcare arrangements

• The emotional difficulty of separation.

But in my experience, that is often not when the real breaking point happens.

Because many women do return.

• They push through.

• They adapt.

• They manage somehow.

And from the outside, it can look like the transition was successful.

But months later - often around the 9–12 month mark - something begins to shift.

The adrenaline wears off.
The “temporary adjustment phase” doesn’t feel temporary anymore.
The exhaustion becomes chronic instead of acute.

And a quiet question begins to emerge:

Can I actually sustain this life long-term?

The Illusion of Stability

The early months after returning to work are often lived in survival mode.

Parents are:

• figuring out routines

• navigating feeding schedules

• handling childcare transitions

• functioning on fragmented sleep

• trying to prove they are still dependable at work

In this phase, many women become extraordinarily efficient.

But efficiency is not the same thing as sustainability.

Sometimes, what workplaces interpret as:

“She’s coping well”

is actually:

“She hasn’t yet had the space to process how difficult this really is.”

What Changes Around 9–12 Months?

This is often when the cumulative strain becomes harder to ignore.

The baby grows, but parenting does not necessarily become easier.

Instead:

• mobility increases

• illnesses become frequent, often with daycare exposure

• sleep disruptions continue unpredictably

• feeding transitions create new stressors

• emotional demands evolve

At work, expectations also begin to shift.

The temporary grace period quietly disappears.

The assumption becomes:

She’s settled now.
Things are back to normal.

But for many women, they are not.

The Mental Load No One Measures

Much of this burden remains invisible because it is cognitive.

Remembering:

• vaccination schedules

• daycare instructions

• pumping timings

• backup childcare plans

• medicines

• feeding preferences

• work deadlines

• household management

All while functioning professionally.

And because women are often expected to carry this load silently and efficiently, the strain is frequently underestimated.

When “Flexible” Isn’t Truly Flexible

Many workplaces today describe themselves as supportive.

There may be:

• hybrid work

• flexible timing

• remote options

And these absolutely help!

But flexibility without realistic workload expectations can simply become:

doing two full-time jobs in the same space.

A mother may technically be home - while simultaneously attending meetings, supervising childcare, coordinating meals, and managing interrupted workdays.

Which means:

Proximity to home is not always the same as support.

This Is Often When Women Begin to Reconsider Their Careers

Not necessarily because they lack ambition.

Not because they are incapable.

But because the system around them feels unsustainable.

This is the stage where many women begin asking:

• Should I step back?

• Should I reduce hours?

• Should I move to a less demanding role?

• Is this career compatible with the life I want right now?

And eventually, for some:

Should I leave altogether?

The Attrition We Don’t Talk About Enough

Women do not always leave during maternity leave itself.

They often leave quietly, months later.

After everyone assumes the transition has been successful.

Which means organisations may completely miss the connection between:

• inadequate long-term support, and

• delayed attrition

The resignation may happen at month 12.

But the process often began much earlier.

What Are We Actually Measuring?

Many organisations celebrate:

• return rates

• rejoining percentages

• maternity policy compliance

But perhaps the more important metric is this:

How many women are still thriving professionally one year later?

Because returning to work is just an event.

Sustaining work after motherhood is an ongoing process.

What Real Support Looks Like

Real support is not just:

• approving leave

• sending flowers

• welcoming someone back warmly

It is recognising that the first year after return is still a transition period.

It looks like:

• realistic workload expectations

• phased reintegration

• protected lactation support

• dependable childcare infrastructure

• managers who allow honest conversations before burnout happens

• workplaces that do not interpret caregiving as reduced commitment

Most importantly, it means understanding this:

Supporting mothers is not simply about kindness.

It is about retention, workforce sustainability, and long-term organisational health.

The Question We Should Be Asking

Perhaps the goal should not simply be:

“Did she come back?”

But:

Did the system make it possible for her to stay without breaking herself in the process?

Because women do not usually leave in the chaos of the early weeks.

They leave later -
when the dust settles,
when exhaustion accumulates,
and when they realise the system was designed to bring them back,
but not necessarily to hold them there.

A few months ago, I came across a phrase I hadn’t heard before: “Sephora Kids.”

It describes a growing trend of preteens, and sometimes even younger children, becoming interested in elaborate skincare routines after watching beauty influencers on social media. Videos of children shopping for anti-ageing creams, retinol serums, exfoliating acids and expensive skincare products have sparked conversations among parents, dermatologists and paediatricians around the world.

At first glance, it may seem harmless. After all, skincare sounds healthier than makeup.

But as with many trends, it’s worth asking an important question:

What does a child’s skin actually need?

Children’s skin is not just smaller adult skin.

Children’s skin is biologically different.

It is thinner, more delicate and continues to mature throughout childhood. The skin barrier, that is the outermost layer that protects against irritants, allergens and water loss, is still developing.

As a result, children’s skin is more susceptible to irritation from products that adults may use without difficulty.

Many products marketed for wrinkles, pigmentation or “glowing skin” were never designed for healthy young skin.

More products don’t mean healthier skin

Social media often celebrates elaborate skincare routines.

Five products become ten.

Morning routines are followed by evening routines.

Serums are layered with toners, exfoliants, masks and moisturisers.

But healthy skin has never depended on the number of products sitting on a bathroom shelf.

In fact, unnecessary skincare products may increase the risk of:

• Skin irritation

• Contact dermatitis

• Dryness and peeling

• Damage to the skin barrier

• Fragrance allergies

Sometimes, the healthiest thing we can do is simply… less.

A closer look at common cosmetic products

1. Retinol and anti-ageing creams

Retinol is a vitamin A derivative commonly used to treat wrinkles, pigmentation and acne in adults. Healthy children’s skin has no need for anti-ageing ingredients. Retinol may cause redness, peeling, dryness and increased sensitivity to sunlight, particularly when used without medical supervision.

2. Chemical exfoliants (AHAs and BHAs)

Alpha hydroxy acids (AHAs) and beta hydroxy acids (BHAs) help remove dead skin cells and improve skin texture in adults. While they have a role in selected dermatological conditions, they may disrupt a child’s delicate skin barrier and lead to irritation, burning or excessive dryness.

3. Fairness or skin-lightening creams

These products offer no health benefit for children.

More importantly, some fairness creams - particularly products purchased online or through unregulated sources - have been found to contain topical steroids, mercury or other harmful ingredients. Even when they do not, they promote the harmful idea that lighter skin is somehow healthier or more beautiful.

Healthy skin comes in every shade.

4. Adult acne treatments

Ingredients such as benzoyl peroxide, adapalene and salicylic acid are valuable medications when used appropriately. However, they should not become part of a routine skincare regimen simply because a child develops an occasional pimple. Persistent or troublesome acne should be assessed by a healthcare professional.

4. Hair dyes

Permanent hair dyes contain chemicals that may trigger allergic reactions, scalp irritation or contact dermatitis. Hair colouring is rarely necessary in childhood, and severe allergic reactions, although uncommon, can occur.

5. Nail polish

Many parents are surprised to learn that modern nail polish is a complex mixture of film-forming agents, solvents, plasticisers, resins, pigments and fragrances.

While today’s reputable brands are generally safer than older formulations, nail polish is still a cosmetic product, not something children need for healthy nails.

Occasional use for a special celebration is unlikely to cause harm, but routine use is unnecessary.

Children frequently bite their nails, suck their fingers or pick at chipped polish. Chipped nail polish can flake off and may be accidentally ingested.

There is another practical consideration that is especially relevant in countries like India, where eating with our hands is common. Nails come into direct contact with food at almost every meal. If nail polish has started to chip or peel, tiny flakes may contaminate food. Although the health impact of occasional ingestion is likely to be small, it is another reason to avoid prolonged wear and to remove polish once it begins to chip.

Healthy nails don’t need colour - they need to be clean, trimmed and well cared for.

6. Perfumes and heavily fragranced products

Fragrance is one of the most common causes of cosmetic-related skin allergy. Perfumed lotions, body sprays and deodorants may trigger irritation, particularly in children with eczema or sensitive skin. Fragrance-free products are often a better choice.

7. Shared makeup and cosmetics

Sharing lipsticks, eye makeup, brushes or sponges can spread bacteria, viruses and fungi. Eye cosmetics, in particular, should never be shared because of the risk of conjunctivitis and other eye infections.

So what do children need?

The answer is refreshingly simple.

For most healthy children:

• A gentle cleanser, when needed

• A moisturiser if the skin is dry

• Daily broad-spectrum sunscreen

• Healthy food

• Plenty of sleep

• Outdoor play

• Regular physical activity

Healthy skin depends far more on everyday habits than on expensive cosmetics.

The conversation goes beyond skincare

As pediatricians, we naturally think about skin health.

But this trend reminds us to think about emotional health too.

When children begin worrying about wrinkles before puberty or believe they need expensive products to have “good skin,” we should ask where these messages are coming from.

Children deserve to grow up believing that:

• Healthy skin doesn’t have to be flawless.

• Beauty isn’t measured by the number of products on a bathroom shelf.

• Confidence comes from who they are - not from what they apply to their skin.

These conversations are every bit as important as choosing the right moisturiser.

What parents can do

You don’t need to ban every cosmetic product.

Instead:

• Keep skincare simple and age-appropriate.

• Read ingredient labels before buying.

• Be cautious about products promoted by influencers.

• Encourage open discussion about any products your child might consider using.

• Talk openly about advertising, filters and edited images.

• Praise children for qualities beyond appearance.

• Model healthy attitudes towards your own body and skin.

Children learn far more from what they see us do than from what we tell them.

Three questions before buying any skincare product

Whenever you’re tempted to buy a cosmetic product for your child, ask yourself:

1. Is this product treating a genuine medical problem?

2. Is it specifically intended for children or recommended by a healthcare professional?

3. Would my child be just as healthy without it?

If the answer to the third question is yes, then the product is probably unnecessary.

The bottom line

Children don’t need complicated skincare routines.

Most of all, they need to know that their worth has never depended on having “perfect” skin.

In a world that increasingly tells children they need to buy more, perhaps the most reassuring message we can give them is this:

Healthy skin isn’t about more products. It’s about gentle care, healthy habits and a healthy sense of self.

What are your thoughts?

Have you noticed children becoming interested in skincare or cosmetics at a younger age? How do you approach these conversations at home or in your clinical practice?

I’d love to hear your experiences in the comments.

There is a story I use when I teach patient safety.

Not because it is easy to hear.

Because it is difficult to forget.

A pharmacy technician was preparing 35 bags of dialysate for an ICU.

She followed the procedure.

She was careful.

She did what she had been trained to do.

But somewhere upstream, potassium chloride and sodium chloride had been shelved in the wrong places.

She reached for what the label told her to reach for.

The label was wrong.

She prepared the solution exactly as instructed.

And what she prepared was lethal.

Two patients died.

The case was documented by Health Quality Alberta, and I keep coming back to it because it captures something that is incredibly difficult for healthcare organizations to accept:

Sometimes the person closest to the patient did not “cause” the error.

The error was already embedded in the system.

The technician was simply where the system’s vulnerabilities finally met a human being.

And that distinction matters.

Because when something goes wrong in healthcare, our first instinct is still remarkably often:

• Who did this?

• Who made the mistake?

• Who failed to check?

• Who didn’t follow the protocol?

• Who should be held responsible?

Those are understandable questions.

But they are not always the most useful questions.

The better question is:

What happened? And why did our system allow it to happen?

That is where patient safety moves from blame to learning.

And it is also where the idea of Just Culture becomes much more interesting than the phrase “blame-free culture.”

“Blame-free” was never supposed to mean “accountability-free”

I have seen this confusion repeatedly in healthcare.

We tell people:

“We want a blame-free culture.”

Everyone nods.

Then someone makes a serious error.

Suddenly, the language changes.

There is an incident meeting.

There are questions about competence.

Someone asks whether the person should be removed from duty.

And eventually, someone says:

“But surely someone has to be accountable.”

They do.

The mistake is assuming that accountability and blame are the same thing.

They aren’t.

A nurse who accidentally selects the wrong medication because two packages look almost identical is not equivalent to a clinician who knowingly bypasses a required safety check because the operating list is running late.

Both may result in harm.

But the behaviours are different.

And if our response is identical, we aren’t practising justice.

We are practising convenience.

This is why I prefer Just Culture to the vague promise of being “blame-free.”

Just Culture asks us to hold two ideas at the same time:

Those statements are not opposites.

In fact, patient safety depends on both.

The problem with judging people after we know the outcome

Here is another uncomfortable truth.

We are very bad at separating behaviour from outcome.

Imagine two doctors who make exactly the same shortcut.

Same decision.

Same risk.

Same departure from the expected process.

One patient is fine.

The other develops a catastrophic complication.

We are much more likely to scrutinize the second doctor.

The first may even be described as experienced, efficient or decisive.

The second may be labelled unsafe.

But what actually changed?

The outcome.

Not the decision.

Healthcare is particularly vulnerable to this because outcomes are so visible.

A patient who deteriorates creates urgency.

A patient who doesn’t deteriorate creates reassurance.

But luck is not a safety strategy.

A risky decision that happens to end well is still a risky decision.

And an adverse outcome does not automatically prove that someone made a bad decision.

That difference is enormous.

After an adverse event, we have the benefit of hindsight.

The clinician didn’t.

The nurse didn’t.

The technician didn’t.

They made their decision with the information, workload, interruptions, resources and constraints that existed at that moment.

If we judge them using information available only after the event, we aren’t conducting a fair review.

We’re conducting a trial with hindsight as the evidence.

Not every error is the same

This is where Just Culture becomes practical.

We need a shared language for behaviour.

1. Human error

A slip, lapse or mistake that was not intended.

The person did not consciously choose the unsafe action.

The response?

Console and learn.

Don’t simply tell the person to “be more careful.”

Ask what made the error possible.

• Was the environment confusing?

• Was the label poorly designed?

• Was there an interruption?

• Was the task overly complex?

• Was the system relying on memory when it could have relied on design?

Human beings will make errors.

The question is whether our systems are designed to catch them before they reach the patient.

2. At-risk behaviour

This is different.

Here, the person chooses a behaviour in which the risk is not fully recognized—or is mistakenly believed to be justified.

Think about the shortcuts that become normalized.

• “Everyone does it.”

• “We’ve always done it this way.”

• “It takes too long if we follow the full process.”

• “Nothing has happened so far.”

This is where coaching becomes important.

Not humiliation.

Not immediate punishment.

Coaching.

What made the shortcut attractive?

What pressures were operating?

Was the safer behaviour actually practical?

Did the system inadvertently reward speed over safety?

Sometimes the individual needs to change.

Sometimes the system needs to change.

Often, both do.

3. Reckless behaviour

Now we cross a different line.

The person understands the substantial risk and consciously disregards it.

That is not simply human fallibility.

That is a behavioural choice.

And there should be consequences.

Accountability matters here.

Not because punishment feels satisfying.

Because professional systems need boundaries.

4. Knowledge-based decisions in difficult situations

Healthcare also has another complication.

Sometimes we knowingly take a risk because the alternative is worse.

Emergency care is full of these decisions.

A clinician may choose an intervention carrying significant risk because not intervening carries an even greater risk.

If we look only at the outcome, that decision may appear reckless.

But context matters.

What alternatives were available?

What was known at the time?

What was the urgency?

What risks were being balanced?

A fair review cannot remove clinical context from clinical decisions.

5. Purposeful harm

And then there are behaviours where harm is intentional.

That is an entirely different category.

We should not dilute our response to deliberate harm by placing it under the broad umbrella of “human error.”

Just Culture cannot live in a policy document

This is where I think many hospitals get it wrong.

They write a policy.

They conduct a workshop.

They put “Just Culture” into the quality manual.

And then everyone waits for culture to change.

It doesn’t.

Culture shows itself in what happens after someone speaks up.

I would frame a practical Just Culture around five commitments.

T — Transparent

People should know in advance how incidents will be assessed.

If I report a near-miss, what happens next?

• Who reviews it?

• What information will be considered?

• When does coaching become discipline?

People cannot trust a system whose rules are revealed only after they enter it.

R — Respond appropriately

The first question should not be:

“Who failed?”

It should be:

“What happened?”

Then:

“Why did it make sense to someone, at that moment, to do what they did?”

That question doesn’t excuse unsafe behaviour.

It helps us understand it.

And understanding is necessary before improvement.

U — Understand

This may be the hardest part.

We need to understand both the person and the system.

A healthcare worker can be responsible for a poor choice without being a bad person.

And a system can contribute to an error without eliminating individual accountability.

We don’t have to choose one.

S — Support

After a serious incident, the patient and family are the priority.

But the staff involved may also need support.

A clinician who has been involved in a devastating event may experience guilt, shame, fear and loss of confidence.

The response should not be:

“Be professional and move on.”

Professionalism does not mean being unaffected by harm.

Support might include peer support, counselling and compassionate leadership.

And importantly, staff need to know the difference between support and investigation.

If I believe that telling you how badly an event has affected me could later be used against me, I may choose silence.

And silence is expensive.

T — Treat people respectfully

This sounds obvious.

It isn’t.

Watch what happens in the first five minutes after an incident.

• Listen to the language.

• “Who was looking after the patient?”

• “Who gave the medication?”

• “Why didn’t she check?”

• “Didn’t he know the policy?”

Those questions may eventually be relevant.

But if they are our opening questions, we have already framed the event as an individual failure.

The second victim, and the first organisational casualty

We rightly focus on the patient and family after an adverse event.

But healthcare workers can also be deeply affected.

The term “second victim” has been used to describe clinicians and other healthcare workers who experience significant emotional distress after an adverse event.

The terminology has been debated, and personally, I think the language matters less than recognizing the experience.

Because I have seen what happens when people carry these events alone.

They replay the case.

They question themselves.

They become afraid of making another mistake.

Sometimes they become afraid of speaking at all.

And when staff stop speaking, something else happens.

The organisation loses its memory.

That may be one of the most dangerous consequences of a punitive culture.

• The nurse who nearly caught the medication error doesn’t report the near-miss.

• The pharmacist who notices a recurring dispensing problem keeps quiet.

• The junior doctor sees a dangerous workaround but decides not to “make trouble.”

A hospital that cannot hear about its vulnerabilities cannot learn from them.

And that is why psychological safety is not merely a “well-being” issue.

It is a patient-safety issue.

Beyond the checklist

There is an irony here.

The pharmacy technician in the opening story followed the checklist.

She did what the system told her to do.

And the system still failed.

That should make us pause whenever our response to an adverse event is:

“We need to remind staff to follow the protocol.”

Sometimes, yes.

But sometimes the protocol itself is not enough.

• Sometimes the wrong product is too easy to pick.

• Sometimes the electronic alert is too easy to override.

• Sometimes the process depends on memory.

• Sometimes the workload makes the “correct” process unrealistic.

• Sometimes the safest behaviour is not the easiest behaviour.

• And sometimes we have designed a system in which a single predictable human error can kill a patient.

That is not simply an individual problem.

It is a design problem.

So, what does Just Culture actually ask of us?

• Not to stop holding people accountable.

• Not to excuse unsafe practice.

• Not to pretend every adverse event is a “system issue.”

• And certainly not to abandon professional standards.

It asks something much more demanding.

Be fair.

Judge the behaviour, not merely the outcome.

Ask what was known at the time, not what became obvious afterward.

Distinguish a slip from a shortcut.

Distinguish a shortcut from recklessness.

And when something goes wrong, don’t stop at the person closest to the patient.

• Follow the chain.

• Look at the environment.

• Look at the design.

• Look at incentives.

• Look at workload.

• Look at communication.

• Look at supervision.

• Look at the assumptions built into the process.

• Look at why the unsafe action seemed reasonable, or possible, in the first place.

Because the purpose of an incident investigation is not to find someone to blame.

It is to make the next occurrence less likely.

And that brings me back to the technician preparing those 35 bags.

She did not need someone to tell her to care more.

She already cared.

She needed a system that did not allow a wrong label and a misplaced product to become a lethal combination.

That is the difference between blaming a person and learning from a system.

And perhaps that is the real “luck trap” in healthcare.

We often judge people by whether their patients happened to survive.

But patient safety cannot depend on luck.

A good outcome does not make an unsafe decision safe.

And a bad outcome does not, by itself, make a good decision negligent.

If we want safer hospitals, we have to become much better at separating the two.

So the next time you are sitting in an incident review, try one small experiment.

That question may lead you somewhere very different.

On August 24, 2026, a fire broke out in the Sick Newborn Care Unit at the District Women’s Hospital in Amravati, Maharashtra.

Three newborns died. Other infants were rescued and evacuated, and an inquiry has been ordered.

The circumstances are still under investigation. Reports have raised questions about equipment, fire-safety systems, and emergency response, but none of that should be treated as established fact until the inquiry concludes.

That distinction matters, because it changes the question worth asking. The instinctive one, that is “who was responsible?”, is the wrong place to start. From a healthcare quality standpoint, the more useful question is: what systems were supposed to prevent this, detect it early, contain it, and protect the patients - and how did those systems actually perform? That’s what I want to dig into here.

A NICU is an extreme test of a safety system

Evacuating a hospital ward during a fire is hard. Evacuating a neonatal ICU is a different order of problem entirely, because a newborn can’t be told to walk to an exit.

Many of the babies in a NICU are on oxygen or a ventilator, wired to monitors, receiving IV fluids or medication, unable to protect their own airway, and completely dependent on staff for every movement. So evacuation isn’t a matter of having a clear exit route. It requires an actual plan: who raises the alarm, who calls for help, who disconnects which equipment, who physically carries each baby, what happens to the ventilated ones, where they’re taken, how they’re prioritized, who handles communication - and what any of that looks like at 3 AM with half the usual staff on the floor.

All of that has to be worked out before the emergency, not during it.

Don’t stop at the immediate cause

Patient safety draws a sharp line between the proximate cause of an event and the conditions that let it become a catastrophe. Say an electrical fault is eventually found to have started the fire: that explains how the fire began, but it doesn’t explain why patients died. For that, you have to look at the layers of protection that were supposed to sit between the fault and the patient: equipment safety, electrical safety, early detection, alarms, suppression, staff response, evacuation, and finally emergency command.

Each layer exists to catch what the one before it missed. This is the basic logic of the Swiss Cheese Model of accident causation, and the lesson is consistent across industries: accidents rarely come from one isolated failure. They happen when several weaknesses line up at once.

Donabedian gives us another way to look at it

One of the simplest frameworks in healthcare quality is Avedis Donabedian’s structure–process–outcome model, and it applies well beyond clinical care.

Structure is what resources and systems exist: fire detection, alarms, suppression systems, electrical infrastructure, safe equipment, backup power, evacuation equipment, staffing levels, physical layout.

Process is how those structures are actually used and maintained: preventive maintenance, safety checks, inspections, drills, training, evacuation procedures, communication protocols, incident escalation.

Outcome is what happened: was the fire caught early, were patients evacuated safely, were there injuries or deaths, was care disrupted.

The value of the framework is that it stops you from making the most common mistake in these situations: looking only at the outcome. A death is an outcome, but it’s also a signal to go investigate everything upstream of it. It should be the start of an investigation, not the end of the conversation.

A certificate is not the same as safety

There’s an uncomfortable question every hospital needs to sit with:

Does compliance actually mean a system is safe?

A hospital can have a fire-safety policy, inspection records, training documentation, maintenance logs, certificates, audit reports - all real, all necessary - and still not know whether the system will work when it’s needed. Policy, compliance, and operational readiness are three different things, and only the last one is proven in practice rather than on paper.

That’s why we cannot consider a fire drill a compliance exercise; it’s actually a test.

• Can staff recognize the alarm and communicate under pressure?

• Do they know their roles?

• Can a baby actually be moved safely, with equipment intact, to a designated area that actually works?

• Does the night shift perform as well as the day shift?

• What happens when the usual route is blocked?

A checklist can’t answer any of that; only a realistic drill can.

The 3 AM test

One of the most useful questions in hospital safety is deceptively simple:

Would this system work at 3 AM?

During the day, a hospital has more staff, administrators on site, senior clinicians, engineers, and easier access to outside help. At night, none of that is guaranteed, and the emergency plan has to work with whoever is actually on the floor. This is why simulation matters: not for another line on an audit form, but because systems behave differently under stress. A plan that looks airtight on paper can fall apart the first time it’s tested, and those failures are useful information if the organization is willing to learn from them.

What would I audit tomorrow morning?

If I were the quality manager of a hospital after a NICU fire, I wouldn’t start with “who made the mistake.”

I would start here:

1. Infrastructure:

Are the fire detection and alarm systems functional? Suppression systems? Are electrical systems inspected regularly? Is backup power reliable? Is oxygen-related fire risk managed appropriately?

2. Equipment:

Is preventive maintenance current? Are electrical safety checks documented? Are high-risk devices monitored, and are faults reported and closed promptly?

3. People:

Do staff know what to do in a fire? Are responsibilities clearly assigned? Is the night shift prepared? Are new hires included in training, and can staff actually demonstrate the required competencies rather than just having sat through a session?

4. Processes:

When was the last fire drill, and was it realistic? What problems came out of it? Were corrective actions assigned — and actually closed, not just logged?

5. Evacuation:

Is there a written NICU evacuation plan? Can a ventilated baby be evacuated safely? Is the equipment available, is there a designated receiving area, and are roles and priorities clear?

6. Communication and command:

Who activates the response? Who takes command? How is information passed along, how are external emergency services brought in, and who talks to the families?

None of these questions are specific to Amravati. Every hospital running a NICU should be asking them.

What should we measure?

This is where leading and lagging indicators come in. Deaths and injuries are lagging indicators: they tell you what already went wrong. What you also need are measures that tell you whether the safety system is functioning before disaster strikes: fire-drill completion, staff competency, alarm testing, preventive-maintenance compliance, equipment checks, how quickly corrective actions get closed out.

The point isn’t to replace outcome measures with process ones - you need both. The principle is simply this: you shouldn’t have to wait for a fire to find out your fire-safety system doesn’t work.

Quality is not about predicting every failure

After a catastrophe, it’s tempting to ask how anyone could have seen it coming. Sometimes the exact event genuinely wasn’t predictable. But quality improvement was never about predicting every possible disaster - it’s about building resilience into the system so that when something does fail, it doesn’t take the patient down with it.

We can’t guarantee equipment will never break, that a fire will never start, or that no one will ever make an error. What we can do is ask how many layers of protection sit between a given failure and the patient, and whether those layers have actually been tested.

From blame to learning

None of this means individual accountability doesn’t matter. If an investigation finds negligence or a deliberate violation of safety requirements, that has to be addressed. But a quality investigation can’t stop there, because even when a person makes an error, there are always further questions: why was the error possible in the first place? Was there an inadequate safeguard, a poorly designed process, insufficient training, an unreasonable workload, hard-to-use equipment? Had something like this nearly happened before, and if so, did the corrective action from that near-miss actually work?

The goal is to find the recurring vulnerability, not the recurring name. A system that only works if every individual in it is perfect isn’t a safe system.

The real measure of safety

Perhaps the most important lesson from any healthcare catastrophe is that safety isn’t the absence of adverse events. A hospital can go years without a fire or a serious equipment failure and that alone proves nothing - sometimes it just means the system hasn’t been tested yet.

Real safety is the ability to prevent, detect, respond, contain, recover, and learn. A resilient organization assumes things will go wrong sometimes, and builds systems that make failure less likely and less damaging when it happens anyway.

What should we do differently tomorrow?

The Amravati fire is a tragedy, and it should be approached first with compassion for the families who lost their newborns and everyone else affected by it. The investigation needs to establish what actually happened. But hospitals don’t need to wait for that final report to ask themselves some basic questions: Would our alarm work? Would our staff know what to do? Could we evacuate a ventilated newborn? Would the night shift be ready? Have we actually tested our emergency systems under realistic conditions — and when the last drill turned up a problem, did we fix it?

These are quality questions, and they are worth asking before the next emergency, not after.

A catastrophic event usually has a visible immediate cause. Quality improvement asks us to look past it - at what vulnerabilities existed beforehand, which safety barriers were supposed to protect the patient, which ones held, which ones didn’t, and what has to change so the next failure doesn’t become the next tragedy.

Healthcare quality isn’t about proving a hospital is safe. It’s about continuously testing whether it is - and fixing the system when the answer is no.

A baby is born, and almost immediately, the advice begins.

Grandparents have something to say.

Neighbours have something to say.

The WhatsApp group has something to say.

Instagram has something to say.

The parenting influencer has something to say.

The product company has something to say.

And then there are the professionals: doctors, nurses, lactation professionals, nutritionists, physiotherapists, sleep consultants, therapists, and a growing number of people who have simply built an audience around talking about health.

For a new parent, it can be almost impossible to tell these voices apart. They often sound the same: confident, reassuring, fluent in medical terms, quick to quote research, backed by thousands of followers, sometimes even by real professional qualifications.

And yet authority and expertise are not the same thing.

The advice starts with good intentions

Much of what families hear isn't malicious. Most of it comes from love. A grandmother remembers what she did with her own children. A friend shares what worked for her baby. Someone in a parenting group recommends what helped their niece. Someone forwards a video because they genuinely believe it might help.

But there's an important difference between "this is what happened to us" and "this is what you should do."

Experience has real value - it gives us stories, perspectives, and sometimes genuinely useful practical wisdom. What it doesn't automatically give us is evidence.

“My baby did this and was fine” cannot tell us whether the same thing is safe for someone else's baby.

And yet that's exactly how so much health advice travels. An anecdote becomes a recommendation. A recommendation becomes a rule. Eventually, the rule becomes "everyone knows this."

Then social media enters the room

Parents today are also surrounded by algorithms giving them a lot of advice. A reel insists that formula feeding is just as good as breastfeeding. Another promises a product that will make a child fairer, more intelligent, taller... Someone is selling a supplement for immunity, intelligence, height, or sleep. Someone has the perfect fix for colic. Someone has the one thing every baby apparently needs.

Many of these claims are inaccurate - but the medium makes them look credible. A beautifully shot video with a confident presenter can feel more authoritative than a carefully written guideline. Someone with a million followers can seem more trustworthy than someone whose expertise took years to build but who never learned how to make a reel go viral.

And advertising has become harder and harder to spot.

Sometimes it looks like education. Sometimes it looks like personal experience. Sometimes it looks like professional advice. Sometimes, uncomfortably, it's all three at once.

And then there are professionals

This is where the conversation gets more uncomfortable, because it's easy to say "don't listen to random people on the internet." But what happens when the person giving the advice actually is a professional?

A qualification matters; but is it a licence to practise every branch of healthcare?

I am a doctor and I did study general surgery in medical school. But if a family member develops a surgical problem, I don't suddenly become their surgeon because I hold a medical degree. I might recognise that something's wrong. I might understand the broad medical issues. I might help them find the right specialist and navigate the system. But I wouldn't give definitive surgical advice just because "doctor" is in my title.

My qualification gives me expertise. It doesn't give me universal expertise. That sounds obvious when we put it this way. Yet somehow we forget the same principle applies across the rest of healthcare too.

Scope of practice matters

A paediatrician caring for a breastfeeding baby needs to understand breastfeeding. A lactation professional working with a mother and newborn needs to understand enough about newborn and maternal health to recognise when something is wrong.

But recognising a problem isn't the same as diagnosing it, or speaking about it authoritatively on social media. And supporting a family isn't the same as becoming every specialist that family might eventually need.

A lactation professional may notice a newborn appearing unusually jaundiced; they should. They may recognise a baby who's lethargic, feeding poorly, or just not behaving as expected; they should. They may ask about a mother's pain, medications, recovery, wellbeing; they should.

But there's a real difference between spotting a red flag and managing the medical problem behind it.

Sometimes the most appropriate professional response is simply: “This needs to be assessed by your paediatrician. Or, please speak to your obstetrician. Or, this is outside my scope of practice.”

You are not failing as an expert. That's expertise being used responsibly.

Parents are navigating an extraordinary amount of noise

Imagine being a new parent right now. A relative says one thing. A friend says another. Your paediatrician says something different again. A lactation professional has yet another take. A parenting influencer disagrees with all of them. Someone in the WhatsApp group has a personal story that sounds incredibly convincing. And Google, unhelpfully, hands you 47 possibilities.

Now add AI to the mix. We have given families unprecedented access to information — but access to information isn't the same as access to interpretation. A search for "baby vomiting after feeds" can take a parent from normal infant reflux to a rare serious disease in a matter of seconds.

An AI response can be beautifully written, deeply reassuring, and completely wrong for the particular child in front of them.

The parent is left trying to work out which voice deserves their trust. And too often, the loudest voice wins.

The problem isn't that everyone talks

I don't think the answer is telling families "only doctors should give advice." Families need community. They need grandparents, other parents, peer support, lactation support, nutrition professionals, therapists, nurses, physiotherapists — healthcare has never been delivered by one profession alone, and lived experience genuinely belongs in these conversations.

The problem begins when experience is presented as expertise, when expertise is stretched outside its scope, or when commercial interest is dressed up as care.

Those are very different things, even when they sound identical.

Maybe we need to teach a different skill

Not "whom should I trust," but "how do I evaluate advice."

When someone hands you health advice, it might help to ask:

- Who is giving this advice, and what are they actually trained to do?

- Is this within their scope of practice?

- What evidence supports it? And is this a personal story or a general recommendation?

- Is there a commercial interest here?

- Is this advice appropriate for this child, this mother?

- What could happen if I follow it?

And maybe the most important question of all: does this situation actually need assessment, rather than advice?

We need professionals who are comfortable saying "I don't know"

Healthcare has always rewarded certainty. Patients like confident doctors. Social media rewards confident creators. Audiences reward people who seem to have an answer for everything. But medicine doesn't actually work that way.

The more we learn, the more we become aware of uncertainty, context, and individual variation.

So perhaps it is not about knowing more. It's knowing the edges of what you know: when to investigate, when to refer, when the evidence is thin, when there's more than one reasonable path, and when the answer simply belongs to someone else.

Because trust comes with responsibility

Families don't need more people speaking with authority. They already have plenty of that. What they need is people who understand what authority actually means.

A qualification carries responsibility. A large following carries responsibility. A trusted relationship with a mother carries responsibility. And professional credibility carries the greatest responsibility of all.

We don't demonstrate expertise by having an answer to every question.

Sometimes we demonstrate it by saying: “I don't know. I'm not the right person to answer that. Let's look at the evidence. This needs a proper assessment. Please speak to the appropriate specialist.”

That may be a less satisfying answer than a confident one. But when it comes to someone's health, knowing when not to give advice is its own form of good care.

Every August 15, we celebrate freedom in India.

We remember the struggle that brought us independence. We think about the freedoms we have today, the freedoms we sometimes take for granted, and the responsibilities that come with them.

As a pediatrician and lactation consultant, Independence Day makes me think about another kind of freedom.

What does freedom mean to a breastfeeding mother?

At first, the answer might seem obvious.

Freedom to breastfeed.

But perhaps it is more complicated than that.

Because a breastfeeding mother needs more than permission to breastfeed.

• She needs the freedom to ask questions.

• The freedom to ask for help.

• The freedom to make informed choices.

• The freedom to change her mind.

• The freedom to struggle without shame.

• And sometimes, the freedom from the enormous amount of noise surrounding breastfeeding.

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Freedom from the noise

Few things come with as much advice as having a baby.

• “Your milk isn’t enough.”

• “Your baby is still hungry.”

• “Give a top-up.”

• “Don’t eat that.”

• “Try this.”

• “That’s how we did it in our time.”

And then there is social media.

One mother swears by one method. Another recommends something completely different. An influencer has a solution. A relative has an opinion. A well-meaning friend has a story about what happened to her.

The mother is left trying to make sense of it all while sleep-deprived and learning how to care for a new human being.

Sometimes the problem isn’t a lack of information.

It’s too much information, coming from too many directions.

Good support doesn’t simply add another voice to the noise.

Sometimes, good support begins with listening.

Freedom to ask for help

We celebrate independence.

But breastfeeding was never meant to be a test of how independently a mother can manage.

A mother should be able to say:

“I’m struggling.”

“My baby isn’t latching.”

“I’m worried about my milk supply.”

“This is painful.”

“I don’t know what to do.”

without being made to feel that she has failed.

We would never tell someone with a broken bone that needing medical help means they are weak.

Why should breastfeeding be different?

Needing support is not failing.

Sometimes the most empowering thing we can do for a mother is to help her understand what is happening and give her the skills and confidence to move forward.

Support does not take away independence.

The right support can create it.

Freedom from guilt and judgement

Breastfeeding carries a strange paradox.

We tell mothers that breastfeeding is natural.

And then, when it doesn’t feel natural or easy, they can wonder what is wrong with them.

Why can’t I do this?

Why isn’t my baby latching?

Why don’t I have enough milk?

Why does everyone else seem to manage?

A mother can begin to feel that every breastfeeding difficulty is a reflection of her ability as a mother.

It isn’t.

Breastfeeding may be biologically natural, but learning to breastfeed is a process.

It involves a mother and a baby learning together. It can be influenced by birth experiences, feeding patterns, anatomy, health, medications, support systems, work, culture and countless other factors.

When difficulties arise, mothers need assessment and support, not blame.

Support should inform, not shame.

Freedom to make informed choices

This, perhaps, is where freedom matters most.

True autonomy isn’t simply telling a mother:

“Do whatever you want.”

That isn’t necessarily empowering.

Real choice requires information.

It means being able to ask:

What is happening?

What does the evidence tell us?

What are my options?

What are the benefits and limitations of each option?

What matters most to me and my baby?

A mother deserves accurate information and skilled assessment, followed by the space to make decisions that are right for her circumstances.

Informed choice is not the same as being left alone.

It means having someone knowledgeable enough to explain, skilled enough to assess and respectful enough to listen.

And it means that the mother remains at the centre of the decision.

Freedom to feed without having to defend herself

There is another freedom we don’t talk about enough.

The freedom to feed her baby without having to defend herself.

At home.

At work.

In public.

In a healthcare setting.

A mother who breastfeeds should not have to explain herself to everyone around her.

And a mother who is struggling should not have to prove that she has tried hard enough before receiving support.

The decision to breastfeed should not become a public debate.

Nor should breastfeeding become a measure of whether a mother is a “good” mother.

How a baby is fed is deeply personal.

Our role as healthcare professionals is to provide evidence, support safety, protect informed choice and help mothers achieve their own feeding goals wherever possible.

Not to turn feeding into a competition.

Independence does not mean doing it alone

Perhaps this is the paradox.

We often think of independence as freedom from needing anyone.

But motherhood teaches us something different.

Sometimes independence means having the confidence to say:

“I need help.”

It means having people around you who don’t take over, but stand beside you.

A partner who protects your rest.

A family member who brings you food instead of giving you another opinion.

A healthcare professional who listens before advising.

A lactation professional who assesses before assuming.

A workplace that understands that returning to work shouldn’t mean returning to zero.

A community where breastfeeding is normal rather than something a mother has to defend.

Independence should not mean isolation.

What kind of support are we creating?

So perhaps, this Independence Day, there is another question worth asking.

Not only:

Are mothers free to breastfeed?

But:

Do mothers have the freedom to breastfeed well-supported?

Can they ask for help without shame?

Can they receive evidence-based information without commercial pressure?

Can they make informed choices without coercion?

Can they change course when circumstances change?

Can they say, “This isn’t working for me,” and still be treated with respect?

Can they breastfeed in public without embarrassment?

Can they return to work without feeling that breastfeeding has to end?

These aren’t merely individual questions.

They are questions about families, workplaces, healthcare systems and society.

Because breastfeeding may happen between a mother and her baby.

But breastfeeding support never happens in isolation.

Perhaps freedom is not the absence of support

Perhaps, after all, maternal independence isn’t about being left alone.

It is about having the freedom to choose the support you need.

To ask.

To question.

To learn.

To decide.

To change.

To say yes.

To say no.

And to feed your baby without feeling that you have to defend your worth as a mother.

This Independence Day, perhaps we can give mothers something more meaningful than another instruction about how they should breastfeed.

Because every mother deserves the opportunity to make informed choices about feeding her baby.

And sometimes, the most empowering thing we can give a mother isn’t independence from support.

It’s the freedom to receive the right support.

🇮🇳 Happy Independence Day.

Behind every successful hospital is an army of professionals most patients never meet.

Walk through any hospital and you will notice the doctors. You will remember the nurse who sat with you when you were scared. You will thank the surgeon on your way out.

What you probably won’t think about is the laboratory scientist who double-checked your blood group before that transfusion, the engineer who made sure the ventilator down the hall never lost power, or the biomedical technician who calibrated the infusion pump quietly delivering your medication drop by drop.

There’s something almost unfair about it: the better these teams do their jobs, the less anyone notices them. We only really think about them when something breaks.

The Architecture Nobody Sees

We talk a lot about patient-centred care, and we should - it’s the right goal. But that care is only possible because of a sprawling, mostly invisible network of support systems working in the background, around the clock.

Every diagnosis, every operation, every ICU admission, every 3 a.m. emergency depends on people the patient will never meet and never thank by name.

What sets these teams apart isn’t just technical skill, though there’s plenty of that. It’s their obsession with quality assurance - the unglamourous discipline of making sure the right thing happens every single time, not just most of the time. In healthcare, you can’t run on luck or individual brilliance. It has to be built into the process itself, so it works even on someone’s worst day.

Nobody claps for a perfectly calibrated analyser or a generator that fires up on cue. But those quiet, unremarkable moments are often the difference between care that’s safe and care that isn’t.

The Laboratory: The Consultant You Never Meet

It is often said that roughly 70% of clinical decisions are shaped, in some way, by laboratory results. Confirming an infection, diagnosing diabetes, cross-matching blood before surgery, tracking a patient through chemotherapy - the lab is quietly involved in almost everything.

Yet most patients couldn’t pick their lab technologist out of a crowd.

Behind every report that lands on a doctor’s screen sits a whole system of checks most people never hear about. Quality control samples get run before real patient samples do. Levey-Jennings charts get reviewed. Westgard rules flag analytical drift before it can affect a result. External Quality Assessment schemes compare a lab’s performance against its peers, so accuracy isn’t just a matter of one institution’s word.

None of this is visible to the clinician reading the result, let alone the patient waiting for it. But it’s the reason that result can be trusted at all.

When the lab is doing its job well, nobody notices. When a potassium value comes back wrong, everybody does.

Diagnostic Imaging: Making the Invisible Visible

A CT scan catches a bleed no one could feel. An ultrasound picks up an ectopic pregnancy before it becomes an emergency. An MRI finds a lesion on the spinal cord that explains months of unexplained symptoms.

Radiologists and radiographers spend their careers making the invisible visible - but the quality behind that goes well beyond producing a clear image.

Every scan has to be justified, optimised, interpreted correctly, and performed safely. That means routine equipment calibration, regular quality control testing, careful monitoring of radiation dose, and strict adherence to standardised protocols. Repeat scans get reviewed and scrutinised, because every unnecessary one means more cost, more delay, and - for anything using ionising radiation - exposure the patient didn’t need to have.

The best imaging departments aren’t chasing beautiful pictures. They’re chasing the right image, of the right patient, at the right time, with the lowest reasonable risk attached to it.

Engineering: The Department That Keeps the Lights On

Picture an ICU with no electricity. An operating theatre with no oxygen supply. A dialysis unit with contaminated water. A neonatal unit that can’t hold its temperature.

Facilities and engineering teams almost never make it into a hospital’s promotional material. But they’re the reason the hospital keeps functioning, hour after hour, day after day.

A backup generator that kicks in the instant the power drops isn’t luck - it is the payoff of preventive maintenance, routine load testing, careful documentation, and contingency planning that nobody thinks about until it’s needed. Water systems get monitored. Medical gas lines get inspected. Fire systems get tested. Air handling units get maintained, because infection control starts with the air itself.

Quality assurance in engineering is really about catching risk before it turns into failure. Every surgery that finishes without interruption, every ventilator that keeps running, every emergency department that stays lit through a storm — that’s engineering, working exactly as it should, and being completely ignored for it.

Biomedical Engineering: The People Who Trust the Machines So You Don’t Have To

Modern medicine runs on equipment: ventilators, defibrillators, infusion pumps, patient monitors, CT scanners. All of it is only as good as its last calibration.

Biomedical engineers install this equipment correctly, calibrate it on schedule, maintain it before it fails rather than after, and fix it fast when something does go wrong. Preventive maintenance plans, performance verification, electrical safety testing, meticulous logs - this is the unglamorous backbone of their work.

Their success isn’t measured in dramatic saves. It’s measured in equipment that simply works, every time, exactly when a clinician reaches for it.

Infection Prevention: Winning by Nothing Happening

No department captures the idea of invisible success quite like infection prevention.

A patient who never develops a surgical site infection. A newborn who never picks up sepsis. An ICU that goes a whole year without an outbreak. None of these make headlines, because they’re defined entirely by absence - by the thing that didn’t happen.

Behind that absence is a lot of unseen work: surveillance systems, hand hygiene audits, environmental monitoring, antimicrobial stewardship programmes, and a steady drumbeat of staff education that never really stops.

The best infection prevention teams are often the most invisible - precisely because they’re succeeding.

Pharmacy: Far More Than Handing Out Pills

Hospital pharmacists do a lot more than count tablets into a bottle. They review every prescription for dangerous interactions, adjust doses for kidney and liver function, drive antimicrobial stewardship, monitor high-risk medications, and work alongside clinicians to get therapy right.

Behind that work is medication reconciliation, independent double-checks on high-alert drugs, barcode verification, storage monitoring, and regular audits of medication safety. Most patients never learn their pharmacist’s name.

Yet they are as much a part of the care team as anyone standing at the bedside.

Quality Assurance: The Hero Behind All the Other Heroes

What ties all of these departments together?

Quality assurance - just expressed differently in each place.

In the lab, it is internal quality control and external quality assessment. In imaging, it is calibration, radiation safety, and protocol discipline. In engineering, it is preventive maintenance and constant monitoring. In infection prevention, it is surveillance and relentless auditing. In pharmacy, it’s the safety checks built into every step between prescription and patient.

Quality assurance isn’t really a department at all. It’s a way of working - one that turns individual expertise into a system patients can rely on, even when they never see it in action.

When it’s working, nobody notices. When it fails, the consequences show up fast, and they show up hard.

Why the Ordinary Days Deserve Some Credit Too

Healthcare loves its heroic moments - the difficult surgery, the dramatic resuscitation, the diagnosis nobody else caught. They deserve every bit of the recognition they get.

But maybe we should make some room to celebrate something quieter: the ordinary day when nothing went wrong.

Because “nothing happened” usually means hundreds of people quietly did their jobs exceptionally well. The lab released accurate results, on time. The imaging equipment produced diagnostic-quality scans from the first patient to the last. The generators fired up on cue during testing, just like they’re supposed to. The infusion pumps delivered exactly what they were meant to deliver. The infection prevention team prevented infections nobody will ever know almost happened. A pharmacist caught a prescribing error before it ever reached the patient.

None of that gets applause. All of it adds up to safe care.

Look a Little Further Next Time

Next time you are in a hospital, look past the consultation rooms and the operating theatres for a moment.

Think about the laboratory scientist. The radiographer. The biomedical engineer. The facilities manager. The infection control nurse. The pharmacist.

Healthcare quality tends to get judged by what patients can see. But it’s held up by the people - and the systems - they never notice: the quality control run accepted before the first sample of the day, the imaging machine calibrated before the first scan, the generator tested before the storm hits, the medication checked and rechecked before it reaches anyone’s bloodstream.

None of it makes headlines. That’s rather the point.

Every August 15, we celebrate freedom in India. We remember the struggle that brought us independence, take stock of the India we’ve built, and think about the one we want to leave behind.

But as a pediatrician, this day gets me thinking about a different kind of freedom — the kind that has nothing to do with voting rights or the freedom to choose a career.

For a child, freedom is simpler than that.

It’s the freedom to just be a child.

The freedom to play

Children need to play — not as a reward once homework is done, not as a gap between tuition, yoga, dance, and skating classes, and definitely not because it photographs well.

Play is how children make sense of their world. They run, climb, build, imagine, negotiate, lose, win, fall down and get back up.

But somewhere along the way, childhood has turned into a packed itinerary — school, homework, tuition, extracurriculars, screens, tests, competitions.

We get so busy preparing children for the future that we forget to let them live in the present.

Not every minute needs to be productive.

Some of the most important things a child learns happen when no one is teaching them anything at all.

The freedom to wonder

Ask any parent — a child’s questions can feel endless.

• Why?

• How?

• When?

• But why though?

• Why does the moon follow the car?

• Why can’t I do that?

And somewhere along the way, a lot of children quietly learn that questions are an inconvenience.

We are in a hurry, so we rush them along. We correct them before they’ve finished wondering. We hand them the answer instead of letting them sit with the question.

But curiosity isn’t something to manage — it is one of the foundations of how children actually learn.

They deserve room to wonder, to ask odd questions, to make connections that don’t quite make sense to us, and sometimes, to just be wrong.

A childhood without curiosity is a childhood that’s been made too small.

The freedom to make mistakes

Of course we want our children to succeed.

But sometimes that wish becomes so strong that we quietly remove every chance they have to fail.

We step in before they struggle. We correct before they’ve even tried. We compare before they’ve had a real shot at figuring themselves out.

Children need safe places to fail in.

A tower can fall. A drawing can turn out terribly. A cricket shot can miss by a mile. A friendship can go sideways. A test can come back with a mark nobody’s happy about — and then they get to try again.

Resilience isn’t built by clearing every obstacle out of a child’s way. It’s built by walking alongside them while they navigate the obstacle themselves.

The freedom to be themselves

Every child is different.

Some are loud, some barely say a word. Some live for competition, some couldn’t care less about winning. Some love numbers, others disappear into storybooks. Some are natural performers, others need time before they find their voice.

And yet childhood so often becomes one long exercise in comparison.

• Why aren’t you like her?

• Look at how well he’s doing.

• Your cousin scored better.

• You should be more confident.

We usually say these things because we want the best for our kids.

But what a child often hears is something else entirely:

Who I am isn’t enough.

Maybe one of the biggest gifts we can give a child is the simple assurance that they don’t have to become someone else to be worthy of love.

They still need guidance, boundaries and encouragement to grow — but they also need room to become who they already are.

The freedom to grow up healthy and safe

There is another side to freedom we don’t talk about enough.

A child can’t experience freedom when hunger is deciding every choice for them. They can’t flourish when an illness goes untreated because healthcare is out of reach. They can’t learn freely when home or the world around them doesn’t feel safe. They can’t dream freely when poverty, violence, discrimination or neglect are the backdrop of everyday life.

For too many children, the freedom to simply be a child is still a privilege, not a given.

And that is why childhood is not merely a family matter. It is a public responsibility.

As pediatricians, we talk a lot about keeping children healthy.

But maybe the goal needs to be bigger than that - not just survival, not just the absence of disease, but the chance to actually flourish.

What kind of childhood are we creating?

We often ask ourselves what kind of India we want to leave for our children.

Maybe there’s a more immediate question worth asking:

What kind of childhood are we giving them right now?

Are they getting enough sleep?

• Enough play?

• Enough time outdoors, away from a screen?

• Enough unstructured time where nothing is scheduled?

• Enough grown-ups around them who actually listen?

• Enough room to make mistakes, and enough protection from real harm?

• Enough acceptance to feel like they belong exactly as they are, and enough space to figure out who that is?

These aren’t small questions.

They are really questions about the kind of society we are building.

Independence begins with childhood

A truly independent India is not just about having children grow up to become successful adults.

It is one where they get to grow up healthy, safe, curious, confident and kind — where a child’s future isn’t decided by the circumstances they happened to be born into.

Where every child gets the chance to learn, to play, to ask questions, to dream, to simply become.

Maybe the best Independence Day gift we can give our children isn’t another achievement, another class, another competition, or another carefully mapped-out future.

Maybe it’s just space.

• Space to play.

• Space to learn.

• Space to wonder.

• Space to dream.

• Space to become.

Because childhood isn’t just a phase we get through and protect along the way.

It is the future we are actually building.

So this Independence Day, maybe the question worth sitting with is a simple one:

Are our children free to be children?

🇮🇳 Happy Independence Day.

It was supposed to be a minor interruption.

A breastfeeding mother needed a small surgical procedure.

Less than an hour under general anesthesia.

She was understandably worried about her baby.

Her lactation consultant was unavailable that day.

So she did what many mothers do when they are unsure about breastfeeding and surgery.

She spoke to her pediatrician.

Her question was simple:

“What will I feed my baby while I am in theatre and until I am awake enough to feed?”

The answer could have been simple too.

1. Feed the baby before leaving.

2. Express and store some milk beforehand.

3. Have that milk available while she was in theatre and during the short period before she was awake and able to safely breastfeed again.

4. Then resume breastfeeding.

But that wasn’t what happened.

The pediatrician prescribed formula.

The family was happy.

It was only for a few hours, they thought.

And it was.

For about eight hours that day, the baby received formula.

Then something else happened.

The family discovered that formula was an available solution.

So, occasionally, when the baby seemed unsettled…

When the baby seemed hungry soon after a feed…

When someone thought the breasts “didn’t feel full”…

When the mother wondered whether she was producing enough…

Formula appeared again.

Not because breastfeeding had failed.

Not because the baby had demonstrated inadequate growth.

Not because there was a documented medical indication.

By six months, the baby was drinking more formula than breast milk.

By ten months, breastfeeding had stopped altogether.

And that is where this story becomes uncomfortable.

Because the surgery wasn’t really the problem.

And the eight hours weren’t really the problem either.

The problem was what happened after those eight hours.

Sometimes the best thing a pediatrician can do is refer

This is not a story about blaming pediatricians.

Pediatricians have an important role in infant feeding.

• We need to recognise inadequate intake.

• We need to assess growth.

• We need to identify illness.

• We need to know when supplementation is medically indicated.

• We need to understand the basic physiology of lactation and the implications of interrupting breastfeeding.

But there is another professional skill that is just as important:

Knowing the limits of our own expertise.

A mother asking how to maintain breastfeeding through a short surgical procedure is asking a lactation-management question.

And if a trained lactation consultant is available, sometimes the best thing the pediatrician can do is simply say:

“Let me connect you with someone who specialises in this.”

That is not passing the buck.

That is good multidisciplinary care.

A pediatrician doesn’t need to become a lactation consultant any more than a lactation consultant needs to become a pediatrician.

We need to know enough about each other’s domains to recognise when the expertise of the other professional is needed.

The question wasn’t “What can the baby have?”

It was:

“How do we protect breastfeeding through this brief interruption?”

Those are two very different questions.

The first question leads naturally to: “We can give formula.”

The second leads to a plan.

Feed before surgery.

Express some milk beforehand if needed.

Store it appropriately.

Have it available for the period of separation.

Know when breastfeeding can safely resume.

Continue milk removal if the separation is long enough to require it.

And then get back to normal.

Current anesthesia guidance is reassuring for breastfeeding mothers: for many procedures, breastfeeding can be resumed once the mother is awake, alert and able to safely feed. Routine “pump and dump” is generally unnecessary.

Of course, individual circumstances matter.

• The infant’s age and medical status matter.

• The procedure matters.

• The anaesthetic and other medications matter.

• The mother’s postoperative condition matters.

But that is precisely why individualised assessment matters.

Not an automatic prescription for formula.

And this is where the lactation consultant matters

There is sometimes an uncomfortable tendency in healthcare to assume that because we are doctors, we should be able to answer every question related to our patients.

We shouldn’t.

Expertise is specialised for a reason.

A trained lactation consultant can help the mother think through:

• when to feed before the procedure

• whether and how much milk to express beforehand

• safe storage and handling of expressed milk

• how to maintain milk removal if separation is prolonged

• how to feed the baby during the brief separation

• how to recognise when a feeding concern actually warrants assessment

• how to protect breastfeeding when supplementation is genuinely necessary

The pediatrician still has an important role.

But the roles are complementary.

The pediatrician assesses the baby. The lactation professional protects and supports lactation. The anaesthetist manages the anaesthesia and perioperative medications.

Good care happens when those pieces connect.

Every prescription carries a message

This is something we sometimes underestimate as clinicians.

When a doctor prescribes something, families don’t only hear the prescription.

They hear a message. They hear: “This is what my baby needs.”

So when formula is prescribed to a breastfeeding mother simply because she will be separated from her baby for a few hours, the family may not interpret it as:

“This is a temporary feeding arrangement.”

They may hear: “The doctor thinks my baby needs formula.”

And that message can persist long after the mother has recovered from anesthesia.

That is why the distinction between medically indicated supplementation and convenience or precautionary supplementation matters.

“The baby isn’t getting enough”

And then there is this phrase.

One of the most powerful sentences in infant feeding:

“I think the baby isn’t getting enough.”

Babies are not particularly good at reassuring adults.

• They cry.

• They cluster feed.

• They have fussy periods.

• They sometimes want to nurse again soon after a feed.

• Breasts become softer.

• Feeding patterns change.

None of these, by themselves, proves inadequate milk intake.

The response to that concern should be:

• Assess.

• Look at the baby.

• Look at growth.

• Look at feeding.

• Look at milk transfer when appropriate.

• Look at urine and stool patterns in the relevant age group.

• Look at the whole clinical picture.

Not automatically:

“Give formula.”

Because once formula becomes the answer to every episode of uncertainty, it can become very difficult for the family to distinguish a baby who needs assessment from a baby who needs supplementation.

They are not the same thing.

A little formula can become a big change

There is also a physiological dimension.

Milk production is a supply-and-demand system.

When a breastfeed is regularly replaced by a formula feed, the breast may receive less stimulation and less milk removal.

Repeated over time, this can reduce milk production.

Then the family sees less breast milk.

That reinforces their original concern.

So they give more formula.

Which means less breast stimulation.

Which can mean still less milk production.

And suddenly the family has what looks like proof:

“See? She really didn’t have enough milk.”

But sometimes what they are seeing is not the original problem.

It is the consequence of the intervention.

That distinction matters.

The missed opportunity was the referral

Perhaps the most important missed opportunity in this story wasn’t simply the prescription.

It was the failure to ask:

“Who is the right person to help this mother with this particular question?”

If the lactation consultant had been available, perhaps the conversation would have been very different.

Perhaps the mother would have learned that she could prepare a small amount of expressed milk.

Perhaps the family would have understood that the separation was temporary.

Perhaps they would have been told exactly when breastfeeding could resume.

Perhaps they would have been reassured about the normal behaviour that later made them worry about milk supply.

And perhaps, when the family later said:

“The baby doesn’t seem satisfied. Should we give some formula?”

someone would have said:

“Before we supplement, let’s find out why you think the baby isn’t getting enough.”

That conversation may have changed everything.

Eight hours can be just eight hours

This story is fictional.

But the pattern deserves our attention.

A bottle given for a few hours becomes a bottle given “just in case.”

“Just in case” becomes “whenever the baby seems hungry.”

And eventually, the family forgets why the formula was introduced in the first place.

The surgery is over.

The anesthesia is over.

But the intervention remains.

Knowing when to hand over is also good medicine

We often celebrate clinicians who can manage everything themselves.

Perhaps we should also celebrate clinicians who know when not to.

• The pediatrician does not have to solve every breastfeeding problem.

• The lactation consultant does not have to diagnose every pediatric problem.

• The surgeon does not have to manage lactation.

• The anesthetist does not have to provide comprehensive breastfeeding counselling.

Each professional brings a different expertise.

The quality of care lies partly in knowing when to connect them.

Sometimes the most valuable prescription a pediatrician can write is not a prescription at all.

It is a referral.

“Please speak to a trained lactation professional.”

Because good medicine isn’t about having every answer.

It is about making sure the mother gets the right answer from the right person at the right time.

And sometimes, that is what protects the breastfeeding journey from becoming collateral damage.

The eight hours

The baby received formula for eight hours.

That was not the end of breastfeeding.

It didn’t have to be.

The eight hours could have remained just eight hours.

What changed the trajectory was everything that came afterwards.

A temporary intervention became a familiar solution.

A familiar solution became reassurance.

Reassurance became routine.

And routine eventually replaced breastfeeding.

So perhaps the lesson isn’t:

“Never give formula.”

It is:

Every year, around World Breastfeeding Week, my hospital room gets a little louder. There are posters going up, reels going out, hashtags trending. For seven days, breastfeeding is everywhere: on Instagram, on hospital noticeboards, in the WhatsApp groups new mothers get added to whether they like it or not.

And every year, I think about Day 8.

Because Day 8 is when the posters come down. The hashtags move on to whatever’s next. And a mother still walks into my clinic, sits down, and says the same thing mothers have said to me for years:

“I don’t think I can do this.”

That sentence doesn’t care what week it is.

We’ve spent this week talking about the mother. Let’s talk about the system.

Over the last six days, we’ve moved through the layers around her: the words we use, the confidence we build, the consistency of what she’s told, what happens when she goes back to work, who shows up for her, and the influences that shape the environment around breastfeeding.

Every layer matters on its own. But put them side by side and something becomes obvious: a mother can be motivated, informed, confident, even beautifully supported at home — and breastfeeding can still become difficult if the environment around her doesn’t hold.

So I’ve stopped asking myself, “How do we get mothers to breastfeed?”

The better question is: How do we build the conditions in which breastfeeding can actually succeed?

That’s not a slogan. It’s a to-do list.

Here’s mine.

1. Strengthen the conversation.

Train the people in white coats to say the same thing, in the same spirit, every time. Listen before advising. Replace fear with evidence, and judgement with support.

Half the damage I see undone in my consults isn’t medical — it’s a sentence someone else said to a tired, frightened new mother three days earlier.

2. Strengthen the continuum.

• Antenatal preparation.

• Skilled support at birth.

• Early follow-up, not “call if there’s a problem.”

• Lactation care that’s actually accessible, not theoretical.

• Support that doesn’t stop the day she walks back into the office.

Breastfeeding support can’t be a single well-meaning conversation in the hospital followed by silence for the next six months.

3. Strengthen the people around her.

Partners, grandparents, employers, community.

Not every one of them needs to become an expert.

But every one of them can learn how to be helpful rather than unintentionally undermining.

That shift alone can change a mother’s experience.

4. Strengthen the safeguards.

This is where the uncomfortable question about industry influence that I wrote about on Day 6 lands today.

We can be open to genuine innovation and still protect families and clinicians from being quietly marketed to.

Evidence matters.

Transparency matters.

The WHO Code and protections such as India’s IMS Act aren’t red tape - they are genuine safeguards that help protect infant feeding from commercial influence.

Good intentions have never been a substitute for a safeguard.

5. Strengthen what already works.

This is the one I keep coming back to.

We don’t need to reinvent breastfeeding support every single year. We already know many of the practices and systems that help: skin-to-skin contact at birth, early and frequent feeding, skilled lactation support, and workplaces that enable mothers to continue breastfeeding after returning to work.

We don’t need to invent anything.

What we need to do is to make what works available, accessible, consistent, equitable and sustained — for every mother, not just the ones who happen to land in a good hospital with a good healthcare professional and a supportive employer.

Seven days can build awareness. They can’t build a system.

Awareness fades the moment the campaign ends. Systems are what’s still standing on Day 8, when nobody’s watching and a mother is sitting in front of you, unsure and a little ashamed of being unsure.

So when she says, “I don’t think I can do this,” what will actually be different?

• Will we have listened differently?

• Communicated more consistently?

• Brought her family into the plan instead of leaving her to manage them?

• Asked what’s actually making this hard for her, instead of repeating advice she’s already heard?

• Made her workplace a little less hostile to the fact that she’s still feeding a baby?

• Kept inappropriate commercial influences a little further from the exam room?

• Held on to the things we already know work, instead of letting them quietly slide?

Maybe that’s what this year’s theme is really asking of us.

- Not more pressure on mothers. More support around them.

- Not another isolated campaign. A continuum that actually holds.

- Not just awareness. Action.

Patients don’t experience healthcare through policies or accreditation certificates. They experience it one conversation at a time.

“The surgery was successful.”

“The infection was treated.”

“The report was normal.”

Hospitals measure these outcomes because they matter. Committees review them. Boards report on them. Regulators audit them. And rightly so. They are, after all, the reason hospitals exist.

But ask patients, months or years later, what they actually remember about their time in hospital, and the answers most often do not sound like outcomes at all.

“The receptionist made me feel welcome.”

“The doctor actually listened.”

“Nobody told me what was happening.”

“One doctor said one thing, another said something else.”

“I went home not knowing what to do.”

None of these are stories about clinical excellence. They’re stories about communication - about whether someone felt seen, informed, and cared for as a person, not just treated as a case.

We tend to file communication under “soft skills,” as though it lives somewhere outside the real realm of medicine: a pleasant extra, nice to have if there is time. But there rarely is time, and communication rarely gets the attention it deserves. Which is strange, because the evidence tells a very different story.

• Communication shapes diagnostic accuracy.

• It shapes patient safety.

• It shapes whether people take their medication, whether they come back for follow-up, whether they trust the system enough to speak up when something feels wrong.

• It shows up in complaint numbers and in litigation.

• It even shows up, eventually, in clinical outcomes.

Communication isn’t an optional extra bolted onto quality. It is one of the most powerful, and most underused, quality interventions a hospital has.

And if you trace almost any patient’s journey from start to finish, you will find the same five conversations recurring, over and over, across specialties, across hospitals, across countries. Get these five right, and the entire experience shifts. Get them wrong, and no amount of clinical brilliance quite makes up for it.

1. The Reception Conversation

Quality begins before a doctor ever walks into the room.

Picture this! You have arrived somewhere you’ve never been before - a building full of corridors you don’t recognize, forms you don’t understand, and a diagnosis or symptom that’s been keeping you up at night. You are anxious. You are a little frightened, even if you’re doing your best not to show it. You don’t know where to go, who to ask, or how long this is going to take.

Before anyone measures your blood pressure or takes your history, you’ve already started forming an opinion about this place. And that opinion is shaped by things that sound almost too ordinary to matter.

Did someone acknowledge you when you walked in? Did anyone smile? Were the instructions clear, or did you have to guess? Did somebody explain how long the wait might be, or did you just sit there watching the clock, wondering if you’d been forgotten? Did the person behind the desk look up from their screen, even for a second?

Hospitals pour enormous resources into buildings, equipment, and branding. Patients, meanwhile, are often responding to something far simpler: whether a human being made eye contact with them at their most vulnerable moment.

The receptionist is almost never part of the conversation about patient safety. Perhaps that needs to change. Because first impressions build trust, and trust is the foundation everything else gets built on. A patient who feels dismissed at the front desk carries that unease into the consultation room, and it colours everything that follows.

QualityPulse – Effective First Impressions in Healthcare

2. The Consultation

We tend to think of the consultation as a process of gathering information - symptoms in, diagnosis out. Patients experience it very differently. For them, this is the moment they decide whether this particular doctor actually understands them.

That decision often turns on a single sentence.

“Tell me what’s been happening.”

Simple. Open. Patient-centred. It hands the story back to the person who’s living it.

Compare that with questions that narrow things down too quickly.

“Where exactly is the pain?”

“How long has it been there?”

These aren’t bad questions; they are necessary for us to reach a diagnosis. They are just not the best place to begin. Asked too early, they turn a conversation into an interrogation, and patients respond by giving shorter, more guarded answers, which means clinicians end up working with less information, not more.

One of the more sobering findings in communication research is just how quickly clinicians interrupt. Studies have repeatedly found that doctors cut patients off within the first few seconds of their opening statement; often before the patient has said anything close to what they came in to say. And yet when patients are simply allowed to finish their opening story without interruption, most of them are done in under two minutes.

Those two minutes often contain the diagnosis. Sitting quietly through them isn’t a courtesy. It’s clinical technique.

Real listening isn’t passive, either. It means noticing facial expressions, body language, tone, the pause before someone answers, the thing they almost said and then didn’t. Patients are communicating constantly — even, maybe especially, in the moments they aren’t speaking. This is part of why structured consultation frameworks matter so much: not because they slow doctors down, but because they make sure nothing essential slips through the gaps of a rushed ten-minute appointment.

The Calgary-Cambridge Guide

One of the most widely used frameworks for this is the Calgary-Cambridge Guide. Rather than treating communication as a bundle of separate skills to master, it structures the whole consultation as a single, coherent conversation. It reminds clinicians to initiate the session properly, gather information without rushing to conclusions, examine the patient with genuine respect, explain findings in language that actually makes sense, involve the patient in decisions about their own care, and close with a plan both people understand and agree on.

Crucially, relationship-building isn’t one stage among many; it runs underneath all of them, start to finish.

The framework doesn’t make consultations longer. It makes them more purposeful. And purposeful conversations, it turns out, are often faster than the meandering ones they replace.

QualityPulse – The Calgary-Cambridge Guide Explained

3. The Handover

Patients tend to assume that hospitals communicate seamlessly behind the scenes, that everyone treating them is working from the same page. The reality is considerably messier.

Modern healthcare is a team sport. Doctors, nurses, pharmacists, radiographers, laboratory staff, physiotherapists - each one sees only a slice of the patient’s story. It is communication that stitches those slices into something whole. Without it, the system doesn’t just slow down. It fragments, quietly, in ways that are easy to miss until something goes wrong.

This is why structured handovers matter as much as they do. One missing detail can delay treatment by hours. One misunderstood instruction - a dose misheard, a result not passed along - can cause real harm.

ISBAR

ISBAR offers a deceptively simple structure for these moments: Identify, Situation, Background, Assessment, Recommendation.

It’s simple on purpose. Communication in the middle of a busy shift needs to be simple, or it doesn’t happen at all — or worse, it happens badly. ISBAR reduces the things that get left out. It clarifies who’s responsible for what. And in doing so, it quietly improves patient safety in a way that rarely gets noticed until you look at what happens when it’s missing.

QualityPulse – ISBAR Explained

Communication Is More Than Handover

Good handovers matter, but hospitals also need teams that function well together across an entire shift, not just at the moments of transition. That’s where TeamSTEPPS comes in.

Rather than zeroing in on a single conversation, TeamSTEPPS looks at how teams communicate continuously throughout patient care — leadership, situation monitoring, mutual support, and communication itself. Notice that communication is only one of four pillars. The other three are really about the conditions that make good communication possible in the first place: people watching out for each other, speaking up when something seems off, and sharing the load instead of letting it pile onto one overwhelmed person.

Patient safety is almost never the responsibility of a single individual having a single good day. It’s the cumulative product of many small, coordinated conversations happening correctly, again and again, often without anyone noticing.

4. Breaking Bad News

Every clinician remembers their first truly difficult conversation. The details tend to stay with them for years: the room, the silence afterward, the look on someone’s face when the meaning of the words finally landed.

No framework removes the sadness from these moments, and no framework should try to. What a good framework can do is to provide structure, so as to help clinicians walk into that room prepared to communicate with genuine compassion, rather than hoping the right words simply arrive in the moment.

SPIKES

The SPIKES protocol asks clinicians to think, in order, about Setting, Perception, Invitation, Knowledge, Emotion, and Strategy and Summary.

What SPIKES really does is slow the moment down. It is a reminder that delivering bad news isn’t simply a matter of transferring information from one person to another - checking a box that says “patient informed.” It is a human encounter, and it deserves to be treated like one.

NURSE

Emotions, in these conversations, deserve a response. Not a solution - a response.

The NURSE framework gives clinicians practical, usable language for exactly that: Name the emotion, show you Understand it, express Respect, offer Support, and Explore what the person is feeling in more depth.

Sometimes the most therapeutic sentence a clinician can offer isn’t clinical at all. It’s simply: “I can see this is overwhelming.”

Communication in these moments isn’t about finding the perfect thing to say. Often, there isn’t one. It’s about being fully present with another person while they absorb something enormous.

QualityPulse – Breaking Bad News with SPIKES and NURSE

5. The Discharge Conversation

There is a certain irony to the fact that one of the most important conversations in the entire hospital stay tends to happen when everyone is in the biggest hurry.

Discharge.

The patient receives prescriptions, appointment dates, warning signs to watch for, lifestyle advice, phone numbers to call if things go wrong, and a follow-up plan: all delivered, often, in the space of a few rushed minutes between one task and the next.

The clinician explains everything carefully, or as carefully as time allows. Then comes the familiar question:

“Do you have any questions?”

The patient smiles politely. “No.”

The next morning, they can’t remember which medicine to take first, or whether the new tablet replaces the old one or sits alongside it.

Teach-back

Instead of asking, “Do you understand?” - a question almost everyone answers “yes” to, whether or not it’s true - try asking something like: “Just so I know I’ve explained it clearly, could you tell me how you’ll take these medicines when you get home?”

That one small shift changes the entire nature of the exchange. It turns discharge from a monologue into a shared conversation, and it means understanding gets checked, not simply assumed and hoped for.

It is a small technique. It also happens to be one of the most evidence-backed ways to reduce readmissions and medication errors after discharge — proof that the gap between “good intentions” and “good outcomes” is often just one better question.

Communication Is the Thread That Connects Quality

Hospitals measure mortality. Readmissions. Infection rates. Waiting times. These metrics matter, and no article about the value of a kind word is going to replace them.

But look closely, and you will find that every one of those outcomes is shaped, at some point, by a conversation. A patient who felt heard at reception is more likely to trust the team later. A patient whose consultation followed a real structure is more likely to be diagnosed correctly the first time. A team that hands over information clearly is less likely to make the kind of small error that becomes a large one. A patient who understood their discharge plan is less likely to be back in that same waiting room within thirty days.

Communication isn’t a separate competency, sitting off to the side of clinical quality. It is the thread running through all of it: the connective tissue that determines whether everything else a hospital does well actually reaches the patient in a form they can use.

Perhaps that’s why patients so rarely remember the policy document, the protocol binder, or the accreditation certificate on the wall. What they remember is how people made them feel, at reception, in the consultation room, during a hard conversation, on the way out the door.

And those memories, for better or worse, are built one conversation at a time.

This piece draws on communication frameworks explored in more depth across the QualityPulse video series - including the Calgary-Cambridge Guide, ISBAR, TeamSTEPPS, SPIKES, NURSE, and Teach-back. Links to each will be added as new episodes go live.

A few days ago, I came across the announcement of a scientific conference on infant nutrition.

The program was impressive.

• International faculty.

• Contemporary topics.

• CME accreditation.

• Sessions on feeding tolerance, the microbiome, human milk oligosaccharides, precision nutrition and long-term outcomes.

Everything a neonatologist would hope for in a continuing medical education programme.

But it made me pause.

Not because of the science.

Not because of the speakers.

But because it prompted me to think about something I had never seriously examined before.

How does the IMS Act apply to scientific conferences?

I wasn’t looking for a violation.

I was looking for an answer.

And the more I read the Act, the more I realised that the question is far more nuanced than I had imagined.

Why this matters

The Infant Milk Substitutes (IMS) Act is often discussed only during World Breastfeeding Week or in conversations about formula marketing.

Yet it affects healthcare professionals more than many of us realise.

Because unlike many public health laws that regulate products, the IMS Act also regulates interactions between manufacturers and the healthcare system.

That makes it relevant whenever we participate in educational activities related to infant feeding.

The IMS Act is India’s choice

Every country approaches the marketing of infant milk substitutes differently.

Some rely primarily on voluntary adoption of the WHO International Code of Marketing of Breast-milk Substitutes.

India chose something different.

Parliament enacted the IMS Act to regulate the production, supply and distribution of infant milk substitutes, feeding bottles and infant foods with the objective of protecting and promoting breastfeeding.

Whether one agrees with every provision or not, it represents India’s public health policy.

As healthcare professionals practising in India, understanding the Act is part of our professional responsibility.

Promotion is broader than advertising

When most people hear the word advertisement, they imagine television commercials or magazine advertisements.

The IMS Act goes much further.

It defines promotion as any direct or indirect method of encouraging the purchase or use of infant milk substitutes, feeding bottles or infant foods.

That single definition changes how we think.

The question is no longer:

“Was a product advertised?”

Instead, it becomes:

“Could an activity directly or indirectly encourage the use of products covered by the Act?”

Those are very different questions.

Scientific education is essential

None of this should be interpreted as suggesting that healthcare professionals should stop learning.

Medicine advances because we continue learning.

Our understanding of neonatal nutrition changes constantly.

Conferences, workshops and scientific discussions are essential.

The question is not whether education should happen.

It absolutely should.

The question is how education can remain independent while maintaining public trust.

The questions we should ask

Whenever we attend a scientific meeting, there are questions worth asking.

• Who is organising it?

• Who funds it?

• Who developed the scientific programme?

• Are speakers free to present evidence that challenges existing practices?

• Are conflicts of interest transparently declared?

These are good questions for every conference.

But they become even more important when the conference deals with infant feeding, breastfeeding, or products covered under the IMS Act.

Not because we assume bias.

Not because we should presume a violation.

But because the IMS Act recognises that educational activities in this area deserve particular scrutiny. As healthcare professionals, understanding that context is part of our professional responsibility.

Why conferences deserve special attention

One provision of the IMS Act surprised me.

It specifically prohibits producers, suppliers and distributors of infant milk substitutes from offering financial contributions or sponsorship to health workers or associations of health workers, including seminars, meetings, conferences, educational courses, fellowships, research work and sponsorship.

Conferences are mentioned explicitly.

That tells us something important.

The law recognises that influence is not limited to advertisements.

Professional education can also shape attitudes, clinical practice and ultimately infant feeding decisions.

Exactly how the law applies to any specific educational activity depends on the facts and should never be assumed.

But the fact that conferences are specifically mentioned means they deserve thoughtful scrutiny.

Strengthen What Works

This year’s World Breastfeeding Week theme reminds us to strengthen what works.

When we hear that phrase, we often think about skilled lactation support, family involvement, workplace policies, or community programs.

Those are all essential.

But there is another system that quietly protects breastfeeding every day.

The laws and ethical frameworks that shape how infant feeding information reaches healthcare professionals and families.

India’s IMS Act is one such safeguard.

It was created not to stop scientific progress, but to ensure that breastfeeding is protected from commercial influences that could undermine informed decision-making.

As healthcare professionals, strengthening what works also means strengthening our commitment to independent, transparent, evidence-based education.

It means asking thoughtful questions about the meetings we attend, the educational resources we use, and the partnerships we enter into.

Not because we distrust science, but because we value it.

Not because we assume commercial influence, but because public trust in our profession depends on our independence.

Supporting breastfeeding is about more than helping one mother and one baby.

It is also about protecting the systems that make evidence-based breastfeeding support possible.

Sometimes, strengthening what works means protecting the science.

Sometimes, it means protecting the law.

And always, it means protecting the trust that families place in us.

When Support Runs Out

There is a moment I see often in clinic.

A mother sits down, baby on her lap, and before I ask a single question, she says,
"I don't think I'm producing enough milk for my baby."

Nine times out of ten, she is.

What's actually run out is her support, not her milk.

Breastfeeding Doesn’t Happen In Isolation

We like to describe breastfeeding as a relationship between a mother and her baby.
And it is.
But it is never only that.

I think of one mother I saw a few months into her baby's life. Milk supply fine. Latch fine. Baby gaining well.

But she hadn't slept more than two hours at a stretch in weeks.

Her mother-in-law kept asking why the baby still "wanted milk all the time."

She had started counting down the days until she went back to work, dreading the conversation with her manager about pumping breaks.

Nothing was wrong with her breastfeeding.

Everything around her breastfeeding was under strain.

The Village Behind Every Breastfeeding Journey

Every breastfeeding journey is shaped by people who may never breastfeed themselves.

- The partner who takes over the 2 a.m. diaper change so that the mom can go straight back to sleep after a feed.

- The grandmother who says "you're doing it right" instead of "in our time, we did it differently."

- The employer who sets up a private room to express milk, not just a policy on paper.

- The nurse who notices, before anyone else does, that the latch isn't quite right — and fixes it before it becomes a crisis.

- The pediatrician who says "let's watch and support" instead of reaching for formula at the first sign of a slow weight gain.

- The friend who texts, simply, "You're doing a great job."

None of these people breastfeed the baby.

But all of them make it possible.

The Power of Small Acts

Support often does not look dramatic. And it is most often not a single grand gesture.

It could be dozens of small acts, repeated, that make the difference between a mother who continues and a mother who quietly gives up and blames herself for it.

A Team Effort

No one person sustains breastfeeding.

• Healthcare professionals provide knowledge.

• Families provide encouragement.

• Communities provide acceptance.

• Workplaces provide opportunity.

Take any one of these away, and the whole thing gets harder, even when the mother and baby are doing everything right.

Strengthen What Works

Breastfeeding works.

The evidence on that has never really been in question.

The question is whether we build the support around it that allows breastfeeding to work.

Breastfeeding may happen between a mother and her baby.

But sustainable breastfeeding begins when we strengthen every part of that team.

Breastfeeding doesn’t end when maternity leave does.

For many mothers, the return-to-work date feels like a deadline for something else too — the end of breastfeeding.

The worry starts weeks in advance.

“Will my supply survive this?”

“Should I just stop now, before it gets complicated?”

“Will my baby even take a bottle?”

“Where will I find the time, or the privacy, to pump?”

“Is it even worth the effort at this point?”

I hear these questions constantly. Not because mothers want to stop. But because they’ve quietly decided that going back to work and continuing to breastfeed can’t both be true.

They can.

There is no single way to do this.

All over the world, mothers keep breastfeeding long after they have returned to work.

Some nurse before they leave in the morning and again the moment they’re home.

Some pump during the day and skip nothing.

Some mix direct feeds with expressed milk, adjusting as they go.

Some change the pattern entirely as their baby grows older.

None of these is the “correct” method. They’re all just methods — different shapes of the same commitment.

The goal was never perfection. It’s a plan that actually fits the family living it.

The work starts before the last day of leave.

The single most useful thing a healthcare professional can offer is preparation beforehand, not false reassurances after the fact.

Preparation is what turns anxiety into a plan.

• When should expressing start?

• How much milk will the baby actually need in a day away from her?

• What’s safe for storing it?

• Who’s doing the feeding while she’s out?

• What happens the day a pumping session gets missed?

None of these are abstract questions. They deserve real, specific answers — not reassurance, not vague encouragement. A plan.

What can the workplace offer?

The workplace is part of the support system, whether it acts like it or not.

Support for breastfeeding doesn’t stop at the hospital exit. It has to follow mothers into offices, schools, shop floors, clinics, and factories — anywhere they clock back in after having a baby.

None of this requires a budget line.

• A clean space with a door that locks.

• A break that isn’t timed to the minute.

• Somewhere cold to store milk.

• A manager who doesn’t make her explain herself.

• Colleagues who don’t raise an eyebrow.

These aren’t big asks. But they’re often the difference between six more weeks of breastfeeding and none.

What about the family?

Families carry this too.

Going back to work rewrites the whole household’s routine — which means partners, grandparents, and other caregivers stop being background support and become central to it.

A partner who takes over washing pump parts and other household chores without being asked.

A grandparent who knows how to handle expressed milk safely.

A caregiver who feeds on the baby’s cues, not the clock.

None of it looks heroic. But stacked together, it’s what lets a mother keep going with any confidence at all.

Support rarely looks dramatic. Usually it just looks like someone else quietly doing their share.

Perfection was never the metric.

Some mothers will stay fully breastfeeding after returning to work. Others will land on a mix of direct feeds and expressed milk. Some will breastfeed only when they’re physically together and let go of the rest.

Every path is different, and none of them is a failure.

Breastfeeding isn’t a pass/ fail exam. Every single feed still counts, whether it’s the only one that day or one of six.

So the real question was never “did she do it perfectly.” It’s “was she supported enough to reach whatever her own goal was.”

This isn’t the practical guide. It’s where the practical guide begins.

This article isn’t about pump schedules, milk storage, or workplace policies.

Those practical strategies matter, and every working mother deserves access to them.

But before any plan can succeed, something else has to happen.

A mother has to believe that returning to work does not mean the end of breastfeeding.

She has to know that support still exists.

She has to feel that continuing is possible.

Practical solutions build on that foundation.

Over the coming months, I will be exploring many of those practical topics—from expressing and storing milk to planning the return to work and creating breastfeeding-friendly workplaces.

Today, the message is simpler.

Going back to work isn’t going back to zero.

Strengthen what already works.

Going back to work was never supposed to mean giving up on breastfeeding.

Give mothers a real plan before they need one. Give workplaces a reason to make room. Give families a way to share the load.

Do that, and breastfeeding doesn’t get harder to sustain — it just stops being something she has to hold up alone.

Reflection for today

If you are working with a mother who is about to go back to her job, ask yourself one thing:

Did you help her build a plan — or did you just answer whatever she happened to ask?

Confidence is not a personality trait here. It is built, in advance, one practical answer at a time.

On her first day home with her baby, a mother asks a simple question:

“How often should I feed my baby?”

The answers begin to arrive.

• “Every two hours.”

• “No, feed on demand.”

• “Your milk looks thin.”

• “The baby is crying because your milk isn’t enough.”

• “Don’t pick the baby up every time.”

• “The baby is using you as a pacifier.”

None of these conversations happen in isolation.

They accumulate.

By the end of the week, the mother is not just trying to breastfeed.

She is also trying to decide who to believe.

The problem is not a lack of advice.

It is a lack of consistency.

Today’s families receive breastfeeding information from many sources:

• Obstetricians

• Paediatricians

• Nurses

• Lactation professionals

• Grandparents

• Friends

• Social media

• Parenting websites

Every voice matters.

But when those voices contradict one another, confidence begins to disappear.

Not because mothers are incapable.

Because they are overwhelmed.

Confusion changes behaviour.

Imagine hearing two different instructions every time you asked for directions.

Eventually, you would stop trusting the map.

Breastfeeding works much the same way.

When advice is inconsistent, mothers begin to question themselves.

• “Maybe I’m doing this wrong.”

• “Perhaps my baby really is hungry.”

• “Maybe I should just give a bottle.”

Confusion leads to doubt.

Doubt changes decisions.

And those decisions can influence breastfeeding outcomes.

Consistency builds trust.

Consistency doesn’t mean that every healthcare professional memorises the same script.

1. It means we communicate the same evidence-based principles.

2. We explain why babies feed frequently.

3. We reassure families that crying has many causes.

4. We assess breastfeeding before suggesting supplementation.

5. We acknowledge uncertainty when it exists.

6. Most importantly, we avoid contradicting one another without good reason.

Families don’t need identical words.

They need coherent messages.

Every member of the team matters.

Breastfeeding support is hardly ever delivered by one person.

It is delivered by a team.

• A nurse who spends five reassuring minutes at the bedside.

• A paediatrician who explains normal newborn behaviour.

• A lactation consultant who observes a complete feed.

• A partner who protects time for skin-to-skin contact.

• A grandmother who says, “You’re doing well. Keep going.”

Every interaction either reinforces confidence, or competes with it.

Before giving advice, ask one question.

“Will what I’m about to say reinforce the support this family has already received?”

If the answer is yes, you’ve strengthened their confidence.

If not, pause.

• Clarify.

• Explain.

• Coordinate.

Because consistency isn’t about professional agreement for its own sake.

It’s about giving families the clarity they need to make informed decisions.

Strengthen what works.

Breastfeeding works.

Support makes it sustainable.

And support is strongest when it is consistent.

One mother should not have to navigate ten conflicting opinions.

She deserves one evidence-based message, delivered with kindness, clarity, and respect.

Because when our voices work together…

Families can too.

Reflection for today

Think about the last breastfeeding consultation you had.

Did your advice reinforce what the family had already been told?

Or did it unintentionally add another conflicting voice?

Sometimes, the most powerful intervention isn’t saying more.

It is making sure we are giving the same evidence-based message.

When we talk about breastfeeding support, we often think about techniques.

• Is the latch deep enough?

• Is the baby transferring milk?

• Is the weight gain adequate?

• Should we correct the positioning?

These questions matter. They are grounded in evidence.

But before any technique can work, something even more fundamental has to happen.

That belief is called breastfeeding self-efficacy - a mother’s confidence in her ability to breastfeed. Research consistently shows that mothers with higher breastfeeding self-efficacy are more likely to initiate breastfeeding, exclusively breastfeed, overcome challenges, and continue breastfeeding for longer.

Confidence is not a personality trait.

It is not something a mother either has or doesn’t have.

It is something that is built—one interaction at a time.

Confidence doesn’t disappear overnight.

It erodes quietly.

Sometimes with a single sentence.

• “Maybe your milk isn’t enough.”

• “The baby is crying because you’re not producing enough milk.”

• “Just give one bottle. It won’t matter.”

Often, these words are spoken with good intentions.

But intention does not always equal impact.

Each conversation can either strengthen confidence or slowly chip away at it.

The opposite is equally true.

A few thoughtful words can completely change the trajectory of a breastfeeding journey.

• “Your baby is still learning, and so are you.”

• “Let’s figure this out together.”

• “Many mothers experience this. You’re not alone.”

• “You’re doing better than you think.”

These are not empty reassurances.

They are evidence-based communication strategies that reduce anxiety, improve confidence, and encourage persistence.

Confidence grows through experience.

• Every successful feed.

• Every concern that is listened to instead of dismissed.

• Every healthcare professional who explains rather than instructs.

• Every partner who says, “I’ll help.”

• Every grandmother who chooses encouragement over criticism.

Confidence grows because support grows.

What healthcare professionals sometimes forget

As clinicians, we naturally focus on solving problems.

• We look for causes.

• We recommend interventions.

• We explain physiology.

But mothers are often asking a different question.

Not,

“Why is this happening?”

Instead,

“Am I doing okay?”

The answer they receive, both verbally and non-verbally, often determines what they do next.

Confidence is a clinical outcome.

We routinely measure:

• Weight gain

• Milk transfer

• Hydration

• Growth

Because confidence influences behaviour.

—> Behaviour influences breastfeeding.

—> Breastfeeding influences health.

Strengthen what works.

Breastfeeding works.

Support makes it sustainable.

And support is not only about solving problems.

Sometimes, the most effective intervention is helping a mother discover that she is already capable.

Confidence isn’t born.

It is built.

Conversation by conversation.

Reflection for today

Before your next interaction with a breastfeeding mother, pause for a moment and ask yourself:

Will my words increase her confidence, or diminish it?

The answer may matter as much as the advice itself.

Healthcare has never had more data.

We measure waiting times, infection rates, readmissions, patient satisfaction, bed occupancy, medication errors, and countless other indicators. Sophisticated dashboards update in real time, and quality meetings are often built around charts, graphs, and performance metrics.

These measurements are essential. They tell us what is happening.

But they rarely tell us why.

Imagine reviewing a monthly report that shows outpatient waiting times have steadily increased over the past three months. The numbers are accurate, the trend is unmistakable, and the pressure to act is immediate. New appointment schedules are proposed. Additional staff are requested. Meetings are called.

Yet one question often remains unanswered:

Has anyone actually gone to see what is happening?

The Wisdom of Gemba

One of the foundational ideas of the Toyota Production System is Gemba, a Japanese word meaning “the actual place.” It refers to the place where work happens and where value is created.

In manufacturing, that place is the factory floor.

In healthcare, it is wherever patients receive care - the outpatient clinic, the emergency department, the ward, the operating theatre, the laboratory, or the pharmacy.

The principle behind Gemba is remarkably simple:

Before trying to improve a process, go and observe it.

• Not through reports.

• Not through assumptions.

• Not through second-hand explanations.

By seeing the work as it actually happens.

What Data Cannot Show

A dashboard may tell you that patients are waiting an hour before seeing a doctor.

Observation may reveal that every patient is asked to provide the same information multiple times.

A report may show delays in administering medications.

Watching the process may reveal that nurses spend several minutes searching for equipment stored in different locations.

An increase in laboratory turnaround time may appear to be a laboratory problem.

Observing the entire patient journey may show that the real delay begins much earlier—with incomplete request forms or specimens arriving in batches.

The difference is subtle but important.

The Discipline of Looking

Going to the Gemba is not about fault-finding or supervising staff. It is an exercise in curiosity.

The goal is not to ask:

“Who made the mistake?”

Instead, ask:

• What is happening here?

• Where does work stop flowing?

• Where do people wait?

• Where is information repeated?

• What makes it difficult for staff to do the right thing every time?

Often, the answers are hiding in plain sight.

Processes evolve gradually. Workarounds become routine. Small inefficiencies become accepted as “the way things are.”

Fresh observation makes the familiar visible again.

Why This Matters

Healthcare is increasingly driven by data, and rightly so. Measurement is indispensable for quality improvement.

But quality cannot be improved from a spreadsheet alone.

The most meaningful improvements often begin with a simple act:

• Standing quietly.

• Watching carefully.

• Listening without interrupting.

• Understanding before changing.

The best quality leaders move comfortably between dashboards and the frontline. They know that data and direct observation are not competing approaches; they complement each other.

This Week’s QualityPulse

Choose one process in your workplace.

Spend just 15 minutes observing it.

• Don’t audit.

• Don’t intervene.

• Don’t offer solutions.

• Simply watch.

Notice where patients wait, where staff search, where information is repeated, where interruptions occur, and where the work flows effortlessly.

You may discover that your most valuable quality improvement opportunity isn’t hidden in a report.

It’s happening right in front of you.

“Breastfeeding works. Support makes it sustainable. Welcome to Day 1 of Strengthen What Works.” - Dr Swathi Padankatti, IBCLC

A mother leaves the hospital with a healthy baby.

Before discharge, she receives advice from several well-meaning people.

“Feed every two hours.”

“No, feed on demand.”

“Your milk hasn’t come in yet.”

“The baby is crying because you’re not producing enough.”

“Just give one formula feed tonight.”

By the third day, she is overwhelmed - not because breastfeeding has failed, but because communication has.

As we begin World Breastfeeding Week 2026, the theme invites us to reflect on a simple but powerful idea:

Breastfeeding for a Sustainable Start in Life: Strengthen What Works.

When we think about strengthening breastfeeding, we often think about new programmes, new technologies, or new initiatives. Yet decades of research have already shown us what works.

• Early skin-to-skin contact

• Rooming-in

• Skilled assessment of breastfeeding

• Timely follow-up

• Family-centred care

• Responsive feeding

These interventions are supported by evidence. But there is one ingredient that quietly connects every one of them.

Communication is often described as a “soft skill.” I believe that description has done it a disservice.

Communication is a clinical intervention.

It is how evidence is translated into practice.

It is how confidence is built.

It is how anxiety is reduced.

It is how families become partners in care rather than passive recipients of advice.

A perfect breastfeeding technique explained poorly is unlikely to succeed. A mother who feels judged is less likely to ask questions. A family receiving conflicting advice is more likely to lose confidence. Even the best clinical recommendations lose their effectiveness when communication is inconsistent, rushed, or impersonal.

In lactation care, communication is not an optional extra. It is part of the treatment.

Every evidence-based breastfeeding intervention depends on someone communicating effectively.

• A healthcare professional who observes an entire feed before offering advice.

• A nurse who notices uncertainty instead of simply checking a box.

• A doctor who explains why a recommendation matters rather than just giving instructions.

• A partner who says, “You’re doing well. Let’s work through this together.”

These conversations rarely appear in clinical guidelines. Yet they often determine whether those guidelines succeed.

For years, healthcare has measured outcomes: exclusive breastfeeding rates, duration of breastfeeding, hospital readmissions, infant growth. These metrics are essential.

But mothers remember something else.

• Did someone truly listen?

• Did anyone acknowledge my fears?

• Did I leave feeling more confident than when I arrived?

These questions are equally important because experience shapes behaviour.

Perhaps communication is the most overlooked breastfeeding intervention. Not because it lacks evidence, but because we have often treated it as a personality trait rather than a clinical competency.

Like clinical examination, communication can be learned, practised, observed, and improved. It deserves the same commitment to training, feedback, and continuous quality improvement that we expect of every other healthcare skill.

This World Breastfeeding Week, perhaps the question isn’t, “What new initiative should we introduce?”

Perhaps it is:

“How can we strengthen the conversations that make every evidence-based intervention more effective?”

Because breastfeeding has always worked.

Our conversations should work just as well.