It is now universally recognised that ‘breast is best’, with both government and global organisations prioritising an increase in initiation and duration of breastfeeding1,2 and current best practice guidelines promoting exclusive breastfeeding for the first six months.
With many hospitals and community settings working towards or attaining UNICEF Baby Friendly status, health professionals and prospective parents alike now have a wealth of data, literature and research available to support this message. Breastfeeding is promoted as the optimum feeding model3 and the latest UNICEF report4 states that significant savings could be made and diseases prevented within the health service if everyone were to breastfeed their offspring.
So why is it that many women who have decided before the birth to commit to breastfeeding abandon it at between four to six weeks, or sometimes as early as the first week? National breastfeeding statistics show a sharp decline in breastfeeding duration rates after six weeks, but more worryingly the decline is evident from as early as two weeks.
So what is going wrong, and more importantly, what can we as health professionals do about it?
Having worked with women and their families over the past seven years providing one-to-one breastfeeding support, either within the family home or in a clinic setting, it would seems that the same issues emerge time and time again:
- Infant weight loss or static weight.
- Insufficient milk supply – perceived or actual.
- Unexpected demands of breastfeeding.
However, none of these can be taken in isolation. Two women may be referred for the same issue but the causes can be very different. Breastfeeding is a physical and emotional journey, and one that is unique to each mother and child. One size does not fit all,5 and in assessing breastfeeding issues it is important to treat each case individually. While checklists may be a helpful tool, it is in spending time listening to women’s experiences of the birth, gathering information about family support, previous breastfeeding experiences (whether positive or negative) and any other family pressures (such as financial problems or long-term health issues), that a true picture emerges.
Problems with infant weight loss may initially point to incorrect latch but on further discussion parents may recount years of IVF treatment and previous miscarriages to achieve a healthy infant – the resulting anxiety that this can produce, especially if the birth itself was traumatic, can have a profound effect on a women’s milk ejection reflex (MER) and subsequent milk production. The advice given here would differ greatly from that of a case of sub-optimal latch.
Receiving feedback from women about their breastfeeding experiences reveals that it is not primarily the cessation of pain or early detection of infection that is more appreciated, but the fact they have been visited in their own home and simply that someone has taken the time to listen to them. It would seem that an opportunity to offload concerns and frustrations in the early postnatal period, whether directly or indirectly related to breastfeeding, really does help improve maternal (and paternal) mood and attitudes towards breastfeeding.
Women need to feel that they are ‘normal’ but often have no benchmark to measure themselves against. The early days of breastfeeding can be very isolating and in many cases women only have the additional support of books and online services to guide them through what can be a very difficult time. New mothers are not forthcoming or honest within their peer group about negative experiences of breastfeeding. Guilt and a sense of failure as mothers are prevalent at a time when women are feeling vulnerable, emotional and uncertain,6 and as such there is a pressure to present a harmonious and easy relationship with breastfeeding, which may not actually reflect the true situation.
This reluctance can lead to mothers, especially first-time mothers, considering themselves alone in finding breastfeeding painful, frustrating and upsetting. This, coupled with the fact that many women live away from their own mothers and families and that culturally in Britain bottle-feeding is regarded as the norm, means that the role of the health professional is vital in supporting and encouraging women to breastfeed during the first few weeks and beyond.
Of course an opportunity to talk about parenthood and its pressure does not in itself bring about a solution to breastfeeding problems. Issues with sub-optimal latch or infection (and the associated nipple pain or breast pain) remain the primary cause for self-referral to the Health On The Streets (HOTS) breastfeeding support service. Shorter hospital stays allow for precious little time to establish breastfeeding, and so problems that begin on the ward are inevitably compounded at home – often to such an extent that by the time the family health visitor carries out the birth visit, breastfeeding has become a painful and distressing battleground or has been abandoned altogether.
Early intervention is the key, and while time constraints are an ever-present issue for health professionals, time invested at the initial visit will be time saved later on. Prompt diagnosis of the root cause of pain, such as thrush or mastitis, results in earlier treatment and in turn has a significant impact on duration rates.
A clear and consistent approach is needed – one which offers a realistic plan to support families through the next few days or weeks. It is important that the families themselves are part of this process to enable them to feel informed and in control.
Many women are concerned about their child’s behaviour at seven to 10 days, citing constant feeding, irritability and crying. They immediately connect this to either illness of the infant or their own insufficient milk supply, and it is the cause of much early breastfeeding anxiety. Imagine their relief to discover this behaviour is typical of an infant undergoing a significant growth period, and perhaps more importantly, to learn that things will settle down. Such anxiety could simply be avoided if families were given this information in advance along with tips on how to manage it. It would serve to reassure women that their child is developing normally and that they are doing a ‘good job’.
It may be that some families require intensive support for two or three weeks until issues have improved or been resolved, and it is perhaps here that other partner agencies and organisations can work alongside the health visiting service in providing that support. The role of breastfeeding champions, local children’s centres, breastfeeding support workers and peer supporters can be pivotal in offering much-needed support to women and their families which, in turn, has a positive impact on duration rates.
So it emerges that in supporting women to breastfeed, health professionals must also, to some extent, act as counsellor. In giving the opportunity for open discussion, providing timely evidence-based information and including families in key decision-making processes, anxieties are eased and the likelihood of maternal low mood, or even depression, is reduced.
Explaining to women what to realistically expect from the challenges of the early weeks helps them to feel confident that both they and their baby are hitting the milestones expected at the right time. This holistic approach to infant feeding - supporting women to be mothers - has a profound effect on self-esteem, well-being and ultimately on how women see themselves as mothers. With care and skill, such an approach encourages women and families to continue along their breastfeeding journey for as long as they wish.
La Leche League
Association of Breastfeeding Mothers
The UNICEF UK Baby Friendly Initiative
1. World Health Organization. Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organization; 2003.
2. DH. Healthy Child Programme: Pregnancy and the First 5 Years of Life - 27 October 2009.
3. Dyson L, Renfrew M, McFadden A, McCormick F, Herbert G,
Thomas J. National Institute Health and Clinical Excellence: Promotion of breastfeeding initiation and duration. Evidence into practice briefing. Available at: www.nice.org.uk/niceMedia/pdf/EAB_Breastfeeding_
4. UNICEF UK BFI. The Seven Point Plan for Sustaining Breastfeeding in the Community (Revised September 2008). London: UNICEF UK BFI; 2008.
5. Jones W. Breastfeeding and Medication. London: Routledge; 2013.
6. Williams K, Donaghue N, Kurz T. “Giving Guilt The Flick”? : An Investigation of Mother’s Talk About Guilt in Relation to Infant Feeding. Psychology of Women Quarterly 2013;37:97.
Rachel Duxbury is a Breastfeeding Support Worker working with the Health on the Streets Team at Baildon Children's Centre, Bradford District Care Trust.
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