Sometimes in Ireland we just knock it out of the park – the plastic bag levy, the smoking ban, the referendum on gay marriage. In these instances we combined forward thinking, a willingness to take a leap, optimism and belief and paved the way for other countries to follow suit.
What if we could do the same for breastfeeding? Our current rates are among the lowest in the world and despite efforts to ‘promote’ breastfeeding and modest investment in supports, we are not really seeing significant improvements. This brings to mind that book from around 20 years back ‘Who Moved My Cheese?’ by Spencer Johnson. From memory, the jist of was this: if something isn’t working, try something else. Think outside the box, be creative. But don’t, like the mice in the book, keep going back to the same spot looking for cheese if there is no longer cheese there.
So what could we do differently? For anyone who’s interested (probably no one), these are just some of the changes I would suggest if I was the boss of breastfeeding in Ireland:
Change how we do antenatal breastfeeding education. Less on the benefits of breastfeeding and the how to of positions, and more on teaching parents about normal new born behaviour – normal sleep patterns, the intense needs of newborns, why they need to feed so much, how to soothe a small baby. And more on the kinds of emotions mothers are likely to feel in the early days and weeks of breastfeeding. Talk about well-being, mental health and transition to motherhood. I believe it’s possible to be positive about breastfeeding while at the same time being realistic about the challenges – breastfeeding challenges and the emotional ups and downs of early days parenting. Studies have found that women want more realistic information and to better prepared for challenges (Williamson et al., 2012; Dietrich Leurer and Misskey, 2015).
Make protecting the golden hours a priority. The HSE National Infant Feeding policy states that where possible all mother-baby dyads should be given one hour of uninterrupted skin to skin contact after birth. But the reality is that in our busy maternity hospitals, it doesn’t always happen the way it should. Skin to skin is interrupted to weigh or check baby. Or interrupted by a staff member giving hands-on assistance to latch a baby. In my ideal world, all mother-baby dyads would be given at least an hour and a half of UNINTERRUPTED skin to skin contact after birth (assuming there are no complications). There would be no pressure for baby to latch. Mother and baby could have time to get to know each other, to celebrate baby’s welcome to the world, and to give baby an opportunity to go through the nine instinctive stages and feed, in his or her own time (Widström et al., 2019). We need to be patient. Babies are not born hungry. They are born needing to be on their mothers chest; their habitat. This is where they need to be, to get their bearings, feel safe, stay warm, regulate their breathing and get themselves organised to order to latch and feed. I really believe that if we prioritise immediate and uninterrupted skin to skin contact after birth, we would see significant changes – more babies latching within the first hours after birth, greater breastfeeding self-efficacy in mothers, more oxytocin – and good things happen when oxytocin flows.
An overhaul of how breastfeeding is supported in the hospital environment. There is a big focus in hospitals on the numbers – easily quantifiable data such percentage weight loss, time feeding (15 minutes each side), every 3 hours, volumes (30ml after each feed), pump for 20 minutes, number of feeds per 24 hours, number of wet and dirty nappies), blood glucose levels. Clinical practices are based on quantitative research on breast milk and lactation. But in many respects it’s not working. The focus on numbers leaves mothers stressed, anxious, and doubting their own ability to nurture their baby. The frequent interruptions interfere with oxytocin and in turn breastfeeding. And many babies end up receiving unnecessary formula supplementation. I would love to see a focus on promoting breastfeeding self-efficacy and less reliance on hands-on support. The research on women’s experiences of breastfeeding tells us that they don’t like it (Spencer, Greatrex-White and Fraser, 2015). According to a 2012 study of women experiencing breastfeeding difficulties, “an intrusive hands-on approach can obviously be experienced as an abuse and as a necessity to be endured. An intrusive hands-on breast approach increases the mother’s sense of being a machine that can be turned off and on by others.” (Palmer et al., 2012)
Consistently studies find that the biggest cause of stopping breastfeeding or introducing formula before intended is perceived insufficient milk supply (Kent et al., 2020). This results from women not only lacking knowledge about breastfeeding but lacking breastfeeding self-efficacy. Verbal guidance to help dyads with positioning and latch is a more mother-centred approach. A client has given me permission to share her account of learning to breastfeed in the hospital after her daughter was born:
“It can take time to learn how to get the baby to latch, for me several failed attempts at the start of each feed for the first week were the norm. I found when on the ward most midwives were quick to want to physically help, but from my perspective, they weren’t coming home with me so if i didn’t figure it out then I was just kicking the can down the road. So I asked them to explain to me how to do it so I would figure it out myself before I was on my own with her in the middle of the night at home! “Could you come back in a few minutes, I’m just going to try myself for a while”. In advocating for those seemingly small experiences, I allowed myself and my daughter space and time to figure it out and I didnt feel the pressure of having someone stand over me while I tried. Four months on I have a happy, healthy, chubby breastfed baby!”
There should also be a greater focus on keeping dyads close during their hospital stay, and allowing staff more time to support mothers with breastfeeding. I’m not suggesting that the numbers don’t matter. They do. But the fact that breastfeeding is a right-brained activity and recent qualitative research on women’s experiences of support need to be considered also.
Stop using formula as a medicine to treat jaundice, low blood glucose, and breastfeeding problems. As above, this requires more midwives and IBCLCs who can provide skilled breastfeeding support, eg help to hand express when baby is not latching or transferring well. And implementation of evidence-based practices that support breastfeeding eg breast milk and skin to skin contact where blood glucose is low. Please note: I am not suggesting formula should never be used or that mothers should not have access to it. But efforts really need to be made to stop it being given to breastfed babies where not clinically indicated.
Cross-cradle hold- Stop!! Most of the mothers I see in private practice have been told in the hospital to feed in cross-cradle hold. Why? It’s often not comfortable and research has found that it leads to more nipple pain that other positions (Thompson et al., 2016). And the practice of pushing babies heads into their mothers breasts is rarely helpful, and does not constitute trauma-informed care. More on this here http://latch.ie/4-reasons-not-push-babys-head-mothers-breast/ Practices to help with latch and positioning should promote breastfeeding self-efficacy, and help mothers to feel empowered, safe and confident in their own abilities to breastfeed. Lactation care should provide a safe space, both emotionally and physically, for women to be able to receive help with breastfeeding (Channell Doig, Jasczynski, Fleishman et al., 2020).
More comprehensive breastfeeding training for midwives AND the resourcing of more dedicated hours for breastfeeding support. It’s neither fair nor realistic to expect hospital midwives to be able to provide individualised and tailored breastfeeding support to new mothers if they are not afforded the time to do it. Providing breastfeeding support is an art and a skill that takes time. It doesn’t happen in a 5 minute time frame. Yes, investment would be required to improve the staffing ratios on postnatal wards. But the long-term benefits of this investment in terms of population health and savings to the HSE would be huge. Imagine if each breastfeeding mother had a midwife skilled in breastfeeding support or an IBCLC spend an hour with her in the days after her baby is born? We owe it to mothers and to babies. What mothers need and want is personalised support from healthcare professionals (Fraser et al., 2020). And we owe it to the many wonderful hospital staff to enable them to do what they do best, to be ‘with woman’.
Change the language. There’s scope for someone to write a discourse analysis on the language we use around breastfeeding and infant feeding. I can’t do it in one paragraph. But in the early post-natal period, when women are vulnerable and very sensitive, the language used when talking about breastfeeding can have a big impact, be it positive or negative. And the language we are using antenatally needs an overhaul. Somehow we need to change the messaging that infant feeding is binary – breastfeeding or formula feeding. It’s more complex than this. What women ‘hear’ antenatally is that six months of exclusive breastfeeding is the gold standard. That it’s what they should do. And what they feel when they don’t achieve this goal is a sense of failure (Ayton, Tesch and Hansen, 2019). Somehow we need to get the message across that any amount of breastfeeding is a good thing and is to be celebrated. This is a blog for another day. But don’t just take it from me. According to Barnes “further research into the facilitative and inhibitive components of health professional language and practices is necessary in order to build supportive discourses around breastfeeding” (Burns et al., 2009).
So in summary, what we need to do is invest funds, expertise and empathy in providing a breastfeeding support model that places women (or the nursing parent) at its heart. Recent qualitative research tells us that in a patriarchal system, women feel under surveillance and expected to perform to a prescribed ideal (Spencer and Fraser, 2018). We talk about women-centred birth, but we need to start talking about women-centred breastfeeding support. Because pushing them to do it for health reasons isn’t working and according to Miriam Labbok, it is a ‘weak strategy’ (Smith, Hausman and Labbok, 2012).
- Ayton, J. E., Tesch, L. and Hansen, E. (2019) ‘Women’s experiences of ceasing to breastfeed: Australian qualitative study’, BMJ Open, 9(5), pp. e026234.
- Burns, E. et al. (2009) ‘A meta-ethnographic synthesis of women’s experience of breastfeeding’, Maternal and child nutrition, 6(3), pp. 201-219.
- Channell Doig, A. et al. 2020. Breastfeeding Among Mothers Who Have Experienced Childhood Maltreatment: A Review. Los Angeles, CA: SAGE Publications.
- Dietrich Leurer, M. and Misskey, E. (2015) ‘The Psychosocial and Emotional Experience of Breastfeeding: Reflections of Mothers’, Global Qualitative Nursing Research, 2, pp. 2333393615611654-2333393615611654.
- Fraser, M. et al. (2020) ‘Important times for breastfeeding support: a qualitative study of mothers’ experiences’, International Journal of Health Promotion & Education, 58(2), pp. 71-82.
- Kent, J. C. et al. (2020) ‘Causes of perception of insufficient milk supply in Western Australian mothers’, Maternal & child nutrition, pp. 1.
- Palmér, L. et al. (2012) ‘Severe breastfeeding difficulties: Existential lostness as a mother—Women’s lived experiences of initiating breastfeeding under severe difficulties’, International journal of qualitative studies on health and well-being, 7(1), pp. 10846-10.
- Smith, P. H., Hausman, B. L. and Labbok, M. H. (2012) Beyond health, beyond choice: breastfeeding constraints and realities. New Brunswick, New Jersey: Rutgers University Press.
- Spencer, R. L. and Fraser, D. M. (2018) ‘‘You’re kinda passing a test’: A phenomenological study of women’s experiences of breastfeeding’, British Journal of Midwifery, 26(11), pp. 724-730.
- Spencer, R. L., Greatrex-White, S. and Fraser, D. M. (2015) ‘‘I thought it would keep them all quiet’. Women’s experiences of breastfeeding as illusions of compliance: an interpretive phenomenological study’, Journal of advanced nursing, 71(5), pp. 1076-1086.
- Thompson, R. et al. (2016) ‘Potential predictors of nipple trauma from an in-home breastfeeding programme: A cross-sectional study’, Women and birth : journal of the Australian College of Midwives, 29(4), pp. 336-344.
- Widström, A. M. et al. (2019) ‘Skin‐to‐skin contact the first hour after birth, underlying implications and clinical practice’, Acta Paediatrica, 108(7), pp. 1192-1204.
- Williamson, I. et al. (2012) ‘‘It should be the most natural thing in the world’: exploring first‐time mothers’ breastfeeding difficulties in the UK using audio‐diaries and interviews’, Maternal and child nutrition, 8(4), pp. 434-447.