Breastfeeding support – what makes it good.

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I’m reading  a lot of research that considers  the best ways to prepare and support women to breastfeed.

Truth is, we really don’t know for certain what’s the most effective way to do it.

One theme that seems to be coming through is that the what isn’t so much of an issue as the how.

When women are asked about what care was helpful to them, they talk about having their feelings acknowledged and being listened to.

Graffy and Taylor (2005) undertook a randomised controlled trial in the UK to measure the outcomes from a particular model of breastfeeding support. As well as this, they asked the women in the trial about what they thought constituted “Good Breastfeeding Support”.

The authors summarised it in 5 points:

1. women wanted good information about the benefits of breastfeeding. This was so they could defend their decision to breastfeed when they were questioned (as they expected to be) by their family and friends (!).*

2. women, as I mentioned above, wanted their feelings acknowledged and wanted to feel listened to.

3.  women wanted practical tips for breastfeeding such as different positions for feeding.

4. they also wanted reassurance and encouragement to breastfeed.

5.  Provision of resources for what to do if they were having trouble – someone to call or make contact with.

Not a bad list.

I would defy any midwife to not know how to provide the elements these women were after.

One of the big points here is that women aren’t expecting a huge amount from their caregivers. Mainly time, patience, a listening ear and some encouragement. You don’t need to solve all their problems….but hey, preventing some would be excellent.

As midwives, we can do this by helping them get to know their new baby – to read the baby’s cues, to offer the breast when the baby is quietly alert, to hold the baby close any time.

To believe them when they say they have tried to feed.

To stay with them when they are going to try.

You don’t need all the answers – you will have seen enough babies to know the range of what is normal – and be amazed by the immense variation in this!

Something I tried to mention to women in clinic when we were talking about breastfeeding at the 26 week visit (probably should have had a chat about it at every single visit…) was: “as midwives we know a lot about lots of different babies …but not so much specifically about yours – you will very quickly become the expert on your baby – you can use us midwives to help along the way with figuring it all out”.

My experience as a volunteer breastfeeding counsellor and then training to be a lactation consultant helped me realise there are more important things than “knowing all the answers” to breastfeeding problems when we are supporting women to breastfeed.

So much more is about walking beside them on the journey.


 

*just by the by…I think this issue needs unpacking (and highlighting) a bit more.  Never mind criticism of the health message “breast is best” – when women are being judged on their decision to breastfeed by their own families!

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Breastfeeding in public. Build a bridge.

I’ve been a subscriber to google alerts for a couple of months now. The topics I am sent include “breastfeeding”, “bottle feeding”, “pregnancy” and “lactation consultants”. I get links to newspaper and magazine articles that the great google machine finds via its keyword searches.

Most days I skim them, some days I read a few and my midwife Facebook friends will know that I often post links that I think are discussion-worthy or particularly interesting.

The breastfeeding posts and links and articles have predominantly been focussed on two things: reported incidents of women breastfeeding who have been asked to cover up or leave the space they’re in. The other topic is how women are unfairly pressured to breastfeed by so-called breastfeeding nazis – a topic I have addressed in another post (More women doing it for longer).

I am coming to think that breastfeeding in public is a key issue for ongoing breastfeeding rates in Western countries. And it’s an issue of human rights…no,dammit, women’s rights.

If a woman is going to have the freedom to leave her home and surrounds with her breastfeeding infant she needs to know that she can feed her baby whenever and wherever she wants to, and more importantly, whenever, wherever and for however long it takes for her baby to feed. With no judgement whatsoever, and even with some encouragement – not a cheer squad, but maybe a nice place to sit and a drink of water.

Women who breastfeed in public are expected to look after the feelings of everyone else who enters that public space. It’s less of an issue that anyone can actually see anything (for example, areola or nipple) and more about the idea that this woman could be breastfeeding.

Breastfeeding women are often being asked to be discreet by the members of the public who see themselves as Reasonable People: “I don’t mind if women breastfeed, but they should be discreet about it”.  These people seem uninformed as to the realities of feeding a live, wriggling child.  And also to how rare sexual exhibitionism is amongst breastfeeding women.

Being a mother of a small baby and toddler can be an isolating experience. A lot of a mother’s time is spent in her own home with her children, attending to her childrens’ needs and running the household. Being able to get out, even if it’s to the shops, is what you need to do every day and sometimes it’s a downright lifeline (please take note shop keepers).

We all expect that when we enter the public sphere we can act as we please, within certain boundaries.

For a breastfeeding mother that means that she will very likely need to breastfeed her child at some point in public.She needs to do that so that she can leave her house, buy food, feel part of a community, stimulate her child, maybe even have a latte…in short, live her life.

Frankly, anyone else’s sensibilities will need to take a back seat if we can agree that, as a member of our society, she has the right to do those things. And breastfeed.

In Australia she has the inalienable legal right to do so.

I know that women’s bodies being displayed in public is a complicated issue in Western society. And breastfeeding is seen as a private activity that shouldn’t (?) be brought into the public sphere. What better way to cut through the hypocrisy around the objectification of women’s bodies than for a mother to carry out a beautiful, physiological activity of love and food with her child?you-can-do-it-breastfeeding

More women doing it for longer.

There has been some talk lately about the pressure placed on women to breastfeed their babies.

Ninety-six percent of women in Australian initiate breastfeeding when their baby is born (Australian National Infant Feeding Survey, 2011), which is a cracking good statistic by world standards. It’s definitely up with the leading leaders in Northern Europe.

The well-worn promotional phrase “breast is best” may well be at least partly responsible for this excellent initiation rate, although breastfeeding advocates are well aware of a more pressing problem – that of keeping women breastfeeding.

In the first week after birth, many, many women who had planned to breastfeed either give their babies infant formula or stop breastfeeding completely. This is despite the best efforts to promote the World Health Organisation’s (and Australia’s National Health and Medical Research Council’s) recommendations that advise there are specific health benefits to babies when they receive ONLY breastmilk in the first six months of life.

The latest figures state that 15 percent of Australian babies are receiving only breastmilk just as they turn six months old.

The question of why this is happening is certainly of interest to breastfeeding advocates and researchers. There is every reason to believe that women who start to breastfeed plan to continue doing so, but as for many health behaviours, the reasons why women enact and sustain breastfeeding are extremely complex, and, I would say, intimately related to the context of their lives. This means that messages like “breast is best” have some power in people’s decision-making, but may not sustain their health behaviours over time.

More influential in the medium term for women breastfeeding their babies might be things like how much time off work a woman has after her baby is born, how supportive and knowledgeable about breastfeeding her friends, partner and family are, how much timely support she gets from health professionals if/when she has difficulties, how comfortable she is breastfeeding in public or even in front of other family members in her own home, and how much she actually enjoys the activity of breastfeeding.

Madeleine Morris’ new book, Guilt-free bottle feeding argues that women have too much pressure placed on them to breastfeed. Earlier, I assumed that 96 percent of Australian women were breastfeeding because they wanted to. It is unsurprising then, that when 96 percent of Australian women start off breastfeeding, our health system is somewhat geared towards supporting them to continue. The known health benefits to mother, baby and community of women breastfeeding might also explain the enthusiasm with which that support is offered.

As for individual guilt, it is generally unhelpful to blame those who helped you try to achieve the goals you set for yourself. Better to protest about the values of a society that purports to like the idea of breastfeeding, but doesn’t provide sufficient affordable, skilled support and education to those trying to do it.

Morris argues that there is really very little difference between breastmilk and baby formula, despite regularly stating throughout the book that of course breastmilk is the best and first choice for feeding a baby. Also confusing is her argument that women want to breastfeed because it is an activity that is inextricably linked in our society to the ideal of a good mother. Rather, the evidence we have suggests that women start and continue to breastfeed because of the health benefits it confers to babies.

There are also many women who struggle to breastfeed in public, whether because of overt comments or because they are worried about the possibility of comments being made. This situation is not likely to be reflective of a society head over heels in love with breastfeeding mothers.

The bigger question remains: if most women start off breastfeeding, why do so many start giving formula as well or stop completely?

To be honest, we don’t know enough about how best to support women to breastfeed. The Cochrane Collaboration’s review paper on support for breastfeeding women particularly mentions the lack of research examining women’s satisfaction with breastfeeding support. My doctoral research will ask women about their experience of care with lactation consultants. I will also observe lactation consultants in practice and talk to them about their work. I am excited by this opportunity to learn about women’s experiences of getting help to breastfeed. It will also be great to observe and talk with the health professionals who support women to breastfeed every day.

There is a happy ending to this story: the Cochrane review also notes that any form of breastfeeding support is most effective in populations with high breastfeeding initiation rates.images-6

Fixing breastfeeding

 

There is no doubt that concerns about infant mortality rates in the USA at the end of the nineteenth century played a role in motivating the medical profession to find new, safe ways of providing nourishment to small babies.

I just can’t work out why there was so little effort to try and work with human lactation.  Wet nurses were (perhaps rightly) widely condemned, but lactation advice seemed to consist solely of offering something else to feed the baby. This complementary feeding almost inevitably led to weaning because of reduced ( or further reduced) feeding at the breast and then reduced stimulation to make more milk.

What about human milk banks? They seem not to have been thought of … formula was the substitute.

Milk sharing must have been endemic, just from the view of infant survival. And it’s a different phenomenon to wet-nursing: a trusted friend or family member provides the milk (and perhaps the breast), rather than a financial transaction. It is an act of trust between mothers. And then there’s the safety of having milk provided to your baby, that another mother is giving her baby. Many of you will know of the special “cousin” or sibling relationship that milk-sharing confers on babies as they grow up in Islamic cultures.

Dr Virginia Thorley is a Lactation Consultant, ABA counsellor and historian who has written about milk sharing:http://www.virginiathorley.com/Links.html

A pervasive and  general mistrust of the functioning of women’s bodies was certainly at play: breastmilk couldn’t be trusted to be consistently wholesome (not surprising given the prescribed conditions necessary for this), women’s bodies were unlikely to be able to produce enough of the stuff, and if there wasn’t enough, you had to give something else instead.

The parallels with men managing childbirth are obvious. Why trust nature when intervention could help so much? Also consider the manipulation of nature with regard to the regulation of rivers and mechanisation of agriculture…

Formula was apparently more attractive because medical practitioners were able to manipulate its contents according to “the baby’s needs”. The implication is that mothers were harder to manipulate! You bet.

But also there was a fundamental distrust of mothers’ ability to care for their babies in general. “Maternal education” was seen as vital to improving infant survival. This was done by means of pamphlets and booklets being produced. But the paediatrician or family physician was seen as the authoritative key to infant well-being. And as he knew little about lactation physiology, most mothers would be bottle-feeding before long.

Thank-you doctor!

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Cult of the mother.

I’ve just spent a good many hours reading a book about the history of infant feeding in the USA.

Mothers and Medicine: a social history of infant feeding 1890-1950. By Rima D.Apple

It has been interesting to learn about the way breastfeeding was viewed at the end of the nineteenth century, just as artificial baby formula was being developed.  Although this is definitely a history of the US experience, we can allow reflections on breastfeeding in Australia where many broad cultural themes were similar, such as the role of science and medicine in everyday life, and the lived experience of women.

The “cult of true motherhood” or the “cult of domesticity” described how women were viewed in the latter part of the nineteenth century: women were defined by their role as mothers, and were entirely responsible for the well-being of their children.  Kind of nice to have the recognition, but at times it would have been a tough load to carry.

In the nineteenth century in the United States, breastfeeding was generally seen as the best way to feed a baby, but the lactating breast was also seen as a sensitive and unpredictable organ: milk supply could be effected by anything from a “fretful temper” to a “fright”, and breastfeeding was likely to overtax the mother’s well-being, causing a “general weariness and fatigue”. Lactating women were encouraged to eat well, exercise a little and cultivate a serene disposition(!).

Go on…breastfeed…just make sure you do it perfectly. Oh, and good luck.

The second best way to feed your baby (should your unpredictable breasts not do your asking, despite your serenity) was for another woman to feed your baby. But wet-nursing was also problematic: how to ensure that this woman from the working class would be eating well, maintaining some serenity and not wasting her precious milk on her own infant? Never mind the enduring view of character being conferred by a baby’s food source.

Infant mortality rates were alarming, criticism of wet nurses widespread. The medical and scientific solution to the problem was to further develop baby formula. Bottle feeding was seen as a thing able to be manipulated by science, unlike the vagaries and uncertainties of that most female of activities: lactation.

And so began an era of medical advice for infant feeding. While mothers were very special people who were expected to take responsibility for their children’s upbringing, they would need a little bit of help from medicine if breastfeeding wasn’t working. That help would be in a bottle of baby formula, perhaps suggested by a doctor qualified in the newest of medical specialties: paediatrics.o-VICTORIAN-BREASTFEEDING-PHOTOS-570