What does that mean – relational?

We all understand that breastfeeding is an activity that feeds a baby and grows a baby. Women who are pregnant undergo complex physiological changes in their bodies that produce colostrum during pregnancy which is the substance for the baby’s first feeds. Once the placenta separates and is born after the baby’s birth the process of lactogenesis 2 begins and some days after this, women start to produce greater volumes of milk in an event colloquially known as the milk “coming in”. This scientific description of the physiology of lactation is the approach commonly taught to health professionals as an introduction to supporting breastfeeding. But how do we support women to breastfeed really?

Breastfeeding rates in western urbanised and industrialised (also known as ‘high income’) countries reflect a reasonably high percentage of women initiating breastfeeding but rates drop away almost immediately with women either weaning or else mixed feeding with infant formula to varying degrees. The World Health Organisation recommends exclusive breastfeeding for the first six months because of the known lifelong health benefits to mother and baby.

So why do women stop or modify their breastfeeding?  And what role does the support we offer to breastfeeding mothers play in these health behaviours?

There are a couple of midwifery researchers who have had a dip at finding out what breastfeeding support provided by midwives looks like – warts and all. They did this with a view to thinking about how it might be done better.

Fiona Dykes conducted a focused ethnographic study of midwives supporting breastfeeding in two UK hospitals to find out what breastfeeding support actually looked like. She found that the time constraints of the postnatal wards meant that midwives provided breastfeeding support in a particular way: breastfeeding was ‘managed’ by midwives through routinised practices and disconnected encounters. This can be understood as a reflection of the structures of the postnatal wards (and the hospital itself) which are based on linear timelines and efficiency of work. It turns out – this is not a good environment for supporting breastfeeding women! We know this because satisfaction levels for postnatal care are downdowndown. We also know that the activities of newborn babies and breastfeeding do not subscribe to linear timelines or indeed to any industrial notions of efficiency. Which is why midwives to resort to the previously mentioned approaches.

Elaine Burns conducted a similar study of Australian midwives and women in two postnatal settings with a slight tweak on the methodology – she carried out a ‘discourse analysis’ on the recorded interactions with midwives and mothers and on the interviews she conducted. This means she was analysing the language in these encounters to gain an understanding of practice. Burns found that breastmilk was constructed by midwives as a precious substance – ‘liquid gold’ – that also resulted in a focus on the production and acquisition of that substance. Breastfeeding was also constructed as a natural and easy thing to do – ‘not rocket science’ – which unfortunately meant that if women were having difficulties they were seen as incompetent. Both of these approaches functioned to distance midwives and women and to exclude relational approach to communication and support.

Does any of this resonate with your own experience of trying to offer breastfeeding support in postnatal environments?

Here are a few examples that seem to illustrate this approach. The first one is what I call the “cult of expressing”. We have definitely created a monster here.  I feel like somewhere at the turn of the 21^st century expressing became a substitute for breastfeeding in hospital. This practice was defended by the idea that all women should learn how to express, but it fits in very conveniently with the above clinical approaches that favour managing breastfeeding as well as valuing breastmilk as a measurable product. With expressing we can all see ‘how much the baby is getting’ and have our anxiety about the reliability (or rather unreliability) of the woman’s body to actually provide for her baby – soothed or else confirmed. And now we can add to this the popularity of antenatal expressing.

Another practice we have is weighing babies on day two after birth and the grading of weight loss into percentages: 7%, 8%, 9%, 10% and over to guide further ‘management’. This practice does not hold up to scrutiny in terms of lactation physiology, protecting babies, supporting breastfeeding or primary research evidence and yet it continues – perhaps because of how well it fits in to the above schemas of quantitative yields and numerical reassurances. Worryingly, this approach may offer false reassurance.

So in my ethnographic study of Lactation Consultant practice, I found that women saw LCs for a variety of breastfeeding ‘problems’. Very often these problems were associated with a disconnection between mother and baby and very often these problems could be traced back to earlier breastfeeding support approaches when in hospital for postnatal care.

Women had generally experienced the care offered in the postnatal environments described by both Dykes and Burns above. The focus had been on ‘getting breastfeeding right’ with taught positions, expressing and very often this approach seemed to result in more entrenched breastfeeding ‘problems’ when the woman’s body did not meet the required standards.

These problems were then countered with breastfeeding ‘plans’ that were centred on disembodying and busy practices of expressing (!), timing of feeds and focusing on milk volumes and weight gain as signs of success. In the process of attempting to solve problems these strategies tended to create new ones in terms of women feeling exhausted and unhappy and disconnected from their baby and breastfeeding being a negative experience.

LCs were observed to spend a great deal of their time in practice reconnecting mothers and babies with each other – physically, emotionally and with a return to relationality through breastfeeding.

So what do we do with all of this?

We need to do better in our postnatal care for breastfeeding women. We need to centre the mother-baby relationship when we support women who are learning to breastfeed and see both women and their babies as capable and ready to breastfeed. The mother-baby dyad are a unit who are built to relate with one another and breastfeeding is one expression of this.

Breastfeeding is the beginning facilitator of this extraordinary, lifelong relationship.

Our postnatal care environments must be relational environments – which means that anything that interferes with the mother -baby relationship must justify its place there or else be removed.

Are we too busy to provide relational care for mothers and babies? The question has to be asked: “what are we too busy doing?”