Is the way we birth causing breastfeeding failure?

I am often asked by my colleagues “why do we need Lactation Consultants?” “There seems to be so many more breastfeeding problems these days. It was never this difficult 20 years ago.”  The answer is simple enough; birth intervention.

The World Health Organisation advises that all babies should be exclusively breastfed for the first six months of life. Complementary foods should only be introduced from six months onwards, continuing breastfeeding in baby’s diet for up to two years of age and beyond. Despite these recommendations and active work from National and State governments to implement BFHI as well as continuing education of staff in almost every health service, a continual decline in the figures is seen month to month in Australia.

WHO is focusing on these main topics to prolong breastfeeding durations:

1.            Nutritional status of mothers who are breastfeeding

2.            Nutrition of infants living in areas with deficiencies, such as in iron, zinc, and vitamin A.

3.            Routine primary healthcare of infants.

Where are the recommendations to look further into the effects of medicalization of birth on the breastfeeding initiation and continuation rates?

It is well documented that initial declines in exclusive breastfeeding in the first month are due to problems with painful nipples and latching problems, a mother’s perceived inadequate breast milk supply and early introduction of formula milk. These problems are often exacerbated when mothers have had a medicalised birth.

In the last few years we have seen many advances in obstetric medicine (whether for the greater good or further problem inducing for the majority; I shall leave for you to decide). We have enabled pregnancy to occur for women who only a decade ago would not have had this opportunity due to age, illness or disability. With such pregnancies often comes high risk obstetric  management during labour; continuous CTG monitoring, induced labour, enforced epidurals which often progresses to inactivity, directed pushing and an increased chance of instrumental or caesarean birth. Of course labour does not have to be considered ‘high risk’ to end up following a medicalised pathway. Even the seemingly innocuous impact of such ‘normal’ pain relieving actions as a shot of pethidine can have unwanted effects on how baby responds once born.  For many of us these are considered within the realms of normal birth and non-interventionist.  A regular occurrence in many birth suites all over the world and considered to be a part of everyday labour. For those babies who have had a combination of several interventions throughout the birth process; induction and augmentation of labour, pethidine, epidural, vacuum delivery or forceps this frequently leads to maternal and neonatal pain, stress and exhaustion. Babies are often separated from their mothers for resuscitation or 24 hours in special care nurseries which in turn can lead to delayed first and subsequent breastfeeds and often to “just one bottle”.  We know how this small ‘gesture’ can have confounding effects on maternal confidence, interruption with milk production and promotes a change from normal newborn behaviours. Intervention whether from birth processes or subsequently due to poor initial neonatal responses, has a great potential to impact significantly on the baby’s ability to breastfeed and respond appropriately.

Jan Riordan found that babies born to mothers who had un-medicated labours had significantly better sucking skills compared to those babies with a medicalised birth. There are some early suggestions that epidural’s can predict lower neurological behaviour scores of newborns, but exposure to epidural analgesia alone was not found to be sufficient to affect breastfeeding ability. It does show that even in normal, healthy newborns, slight differences in central nervous system functioning was sufficient to affect breastfeeding on the 1st day of life. The majority of other findings, though, are not yet conclusive on whether epidurals specifically affect breastfeeding success rates.

During an epidural continuous IV fluid will be given throughout the course of labour and if over several hours this could be several litres. A pregnant women already carries an increased fluid volume and add to that the antidiuretic hormone, vasopressin, which  exacerbates the fluid retention further and we can see how this is often responsible for breast and areola oedema we see at 2-4 days postpartum. This oedema and engorgement can last for up to 14 days. It makes the breasts very painful due to the increasing tightness surrounding the areola, babies can find it increasingly difficult to latch on to the breast and effectively drain the milk. This can be very uncomfortable and upsetting for mothers making it hard for her to breastfeed unaided.  Reverse Pressure Softening (RPS) technique is recommended prior to every feed to relieve the oedema.  Expressing the milk out prior to feeds will exacerbate this condition further if RPS has not pushed back the oedema first. See Jean Cotterman’s explanation here.

Birth trauma must not be only looked at in terms of the medical intervention involved but also the potentially disturbing psychological effects thereafter. A very good qualitative account following mothers from the US, UK, Australia and NZ found several recurring themes that either impeded or enhanced a new mother’s ability to breastfeed. The 5 themes  women reported  that had disrupted and intervened with their ability to continue breastfeeding  were:

  • Intrusive flashbacks of the birth
  • Enduring pain
  • Feeling violated
  • Detachment from their baby
  • Perceived low milk supply.

Too often we separate birth from breastfeeding as if they are two separate entities. How many women are informed that the type of birth they have may impact on their baby’s ability to breastfeed? Do we even discuss the effects of perineal pain or surgical scarring and the mother’s ability to sit comfortably and feed her baby? Do we give enough support and time to mothers who have had a medicalised, if not traumatic, birth? Are we able to build self-esteem and confidence in the small amount of time allocated to women’s psychological needs in hospital postnatal wards? If the evidence and our own knowledge supports this, why is there often little value and respect given to the midwife who spends time listening and talking with a mother, instead of the midwife who completes her tick-list of physical maternal checks? Do we value productivity over holistic care?

So how can we best help those babies who are neurologically impaired and not yet interested to feed? The most helpful answer is to go back to basics. A mother who has had a medicalised birth does not need another ‘expert’ to help her get breastfeeding going.  Long labours, drugs and intervention lead to exhausted mothers and babies. At this time it is difficult for new mums to absorb and process new information. Let her hormones do the thinking by keeping mother and baby together, preferably in skin to skin contact and for as long as possible. Allowing both to rest and recuperate.

Hopefully the parents have been taught antenatally about the benefits of establishing milk supply early and are able to initiate hand expression without having to take on board too much new information.  By maintaining babies sugar levels with frequently (2-4hourly) expressed colostrum until baby is ready to establish breastfeeds will ensure mother and baby are left alone together. This ‘us’ time can enhance bonding, reduce cortisol levels in mother and baby and allow gentle recuperation.  Once baby is ready she will crawl down from her comfy spot, in-between mother’s breasts, find the nipple and initiate an instinctive Biological Nurturing form of attachment; baby led and mother learnt.

In a nutshell:

  • Skin to skin contact (prolonged)
  • Keep baby close to the nipple. Smell, smell and more smell, important!
  • Express some colostrum onto nipple and baby’s mouth
  • No strong smells of perfume on mum (future post to come re baby’s sense of smell and the relevance to breastfeeding).
  • If baby doesn’t want to feed yet, offer help to the mother to aid her hand expressing her colostrum every 2-3 hourly.  Give all EBM to baby.
  • Reassure, Reassure, Reassure! Mums need to be calm and relaxed to help milk to flow and provide a reassuring environment for her newborn. Loving partners can give a well needed shoulder massage which will enhance oxytocin and help milk to flow.
  • Once baby wants to breastfeed try the laid back style of Biological Nurturing to keep mum and baby relaxed. See this link to watch clip on biological nurturing.

If we leave mothers without adequate lactation support in the first few days and weeks we will inevitably continue to see this rapid decline in breastfeeding rates.  Government initiatives have introduced BFHI into many hospitals but yet we see the biggest decline in breastfeeding after the first week; once mother and baby have left the hospital.  How are breastfeeding rates to increase if we discontinue our lactation support at a mother’s most vulnerable stage? I admit, in many community areas there is fantastic support services for mothers and babies; I have worked in breastfeeding and postnatal drop-ins in both in the UK and Australia with amazing results. I have also worked as a community midwife in the UK for many years, but looking back even though most mothers received 3-4 postnatal home visits I felt we often did not provide the time needed.  Unfortunately drop-ins and home visits are still not universal and prolonged postnatal care and lactation support is not on a high agenda for local or national governments.  If we are to make a change we need to stand up for the basic rights of new parents to all receive universal support and care in the first 4-8 weeks.  Lobby your local government, make breastfeeding awareness week count, be heard, stay positive and give and seek the best care possible.

Referrences:

Beck, Cheryl, Tatano, Watson, Sue 2008, Impact of Birth Trauma on Breast-feeding: A Tale of Two Pathways Issue: vol. 57 (4), July/August , pp. 228-236

Colson S (2007) Non prescriptive recipe for breastfeeding. Available at: http://www.biologicalnurturing.com/pages/downloadarticles.html

Cotterman, KJ 2004 Reverse Pressure Softening: A simple tool to prepare areola for easier latching during engorgement . J Human Lactation, 20, 227-237.

Growing Up In Australia: Longitudinal Study of Australian Children (LSAC) – Annual Report 2006-07 – Breastfeeding.  Available at: http://www.aifs.gov.au/growingup/pubs/ar/ar200607/breastfeeding.html  viewed 01 October 2011

Halpern, SH Levine,T  Wilson, DB MacDonell, J Katsiris, SE & Leighton, BL 1999 Effect of labor analgesia on breastfeeding success. Birth, 26, 83–88.

Infant Feeding Survey 2005. Published May 2007. Available at: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/infant-feeding-survey/infant-feeding-survey-2005 Viewed 06 November 2011

New Zealand Ministry of Health, (2002). Breastfeeding: A guide to action

Radzyminski, S  2005Neurobehavioral Functioning and Breastfeeding Behaviour in the Newborn JOGGN Clinical Research, May/June

Rajan, L 1994 The impact of obstetric procedures and analgesia/anaesthesia during labour and delivery on breast feeding. Midwifery, 10, 87–103.

Riordan, J Gross, A  Angeron, J Krumwiede, B & Melin, J 2000, The effect of labor pain relief medication on neonatal suckling and breastfeeding duration.  Journal of Human Lactation, 16, 7–12.

Scherer, R Holzgreve, W  1995, Influence of epidural analgesia on fetal and neonatal well-being. Eur J Obstet Gynecol Reprod Biol,  May; 59, 17-29.

Thompson, RE Kildea, SV Barclay, LM et al. 2011, An account of significant events influencing Australian breastfeeding practice over the last 40 years. Women and Birth: the Journal of the Australian College of Midwives, Vol. 24, no. 3, pp. 97-104

World Health Organization 2002, The optimal duration of exclusive breastfeeding: Report of an expert consultation. Geneva, Switzerland.

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17 Comments to “Is the way we birth causing breastfeeding failure?”

  1. Thankyou for another wonderful post! I LOVE your emphasis on letting mum and baby establish breastfeeding biologically and not forcing bub onto the boob.

  2. Thanks for a great article. The birth of my son was traumatic with lots of intervention. The first feeding experience consisted of the midwife squeezing my breast and causing pain. I was pretty much told to deal with it.
    I happened to get an infection after my c section and spent time in hospital and couldn’t feed due to exhaustion and being really ill. But I had a wonderful consultant who helped me pump daily and when I was off all antibiotics I continued to breastfeed my son until he was 6 months. I admire what you do and take my hat off to you.

    • Thanks Jenni. It is so important to get the right support, look what happens when you do 6 months of breastfeeding, fantastic. I think it is one of the saddest things that not all mothers know about or have access to good Lactation support. Unfortunately I (pessimistically) don’t think we will be able to change current birthing practices for the masses any time soon, so governments and local areas need to make sure good, effective care is available to every mother for her to feel confident breastfeeding.

  3. Thanks for this. I agree – as a society we have allowed lactation support to go to the wayside. From my perspective, there are other factors to assess as well. I am a Registered Nurse, and have worked in the post partum period in the community as well as in the acute phases. With no training. Zero. Absolutely nil. Along with many colleagues and fellow nursing students/full time nurses. It’s ridiculous that I was even allowed to walk into the room of a mother attempting to latch and even allowed to respectfully enter into that relationship. I know some of the units do a bit of intensive study while they are being oriented, AND they rely on the unit having lactation support for special circumstances. But what about the Labour and Delivery units? What about community? We have community LC’s and La Leche League, but when a mother has access to the formula delivery coming after she’s purchased maternity clothes, bought a magazine, etc… there is not a chance that establishing rates beyond six months can happen. We need to amass a large response to this. If you’re reading, please join http://www.mothersofchange.com and look to other local initiatives. Talk to mothers, send letters to the ministry of health, get involved in your local community of doulas and LC’s and other supports. Help mothers who are in their birthing years to make connections. Take over meals, help with simple tasks so that she can concentrate on her baby. Maybe by paying it forward and getting involved we can tackle part of the problem.

    • It is amazing to me how we treat birth so differently in every country. I am still amazed at how each country has different policies related to advertising of formula milk, when we have a comprehensive WHO code. You are right Rhonda, we as women need to stand up and protect our fellow mother, sister, friend from false advertising and dangerous promotion of formula milk and commencing solids early. We need to pay more attention to giving up our time to new mothers, not giving a shiny new present. A well timed and lovingly prepared meal, a shoulder to cry on or a gentle stroll to lift the spirits and talk is as, if not more important than any material gift.
      Very good reading at http://www.mothersofchange.com thankyou Rhonda.

  4. Thank you for this important and timely article. I believe that not only does the way we birth interfere but also the very interventionist way we are “supporting” BF are both responsible for MUCH of the normal infant feeding problems facing the US and some other societies. I am an IBCLC and I am in a very small minority with my minimally (if ever ) interventionist ways. I am quietly appalled when I hear the very interventionist approaches from other IBCLCs that scream about birth interventions yet think nothing of it when it comes to BF. Some dyads do absolutely need interventions but the vast majority just need the QUIET and time to recuperate from a traumatic birth experience and early separation and lots of bonding and kangaroo care and loving support and encouragement to be able to do what comes naturally for both. We need to normalize normal infant behavior and need and stop being so instructive about infant feeding. Loving and compassionate education and encouragement can accomplish so much.

  5. I also think that when breast feeding was the norm women were surrounded by other women that knew how to help moms succeed. My mother really thought my babies were starving becasue they always seemed hungry and sometimes fussy at the breast. She did understand how quickly breast milk is digested and how those fussy moments are often growth spurts where baby is trying to keep up the milk supply.

    • You are absolutely right, good support and continued encouragement from family members is essential. The midwife is unlikely to be there at 3am when things can seem really difficult for the mother. Then it is imperative to have someone who supports and values her decision to breastfeed, as well as understands that things worth doing can sometimes be hard work initially, but worth continuing.

  6. I live in the Netherlands. Here, homebirthing is seen as normal, and about 1/3 of all Dutch babies are born at home, without intervention. Midwife care is also the standard, with OBs only stepping in if the pregnancy is high-risk, or if problems arise. In addition to this, there is a high level of home care provided in the first week after the baby’s birth. A ‘kraamverzorgster’ (lit: postpartum carer), comes into your home for between 4 and 8 hours per day (depending on your health insurance level. Health insurance is legally required for every Dutch adult, and the minimum kraamzorg insurers can offer is 4 hours pd), for 8 days. She weighs and checks baby daily, helps with household chores, and makes tea for the masses of visitors that come along to see the new baby, amongst other things. This allows mom and baby to stick together and relax, and is particularly helpful for first-time moms, as they are literally taught how to care for their baby. And one of the major things a kraamverzorgster does is to help the new mom establish breastfeeding. In spite of this, many Dutch women stop breastfeeding at 6 weeks.

    In light of the article above, I’d be interested to know whether rates of successful breastfeeding (even if it is just for 6 weeks), are better in the Netherlands. More births tend to be natural here, and post-partum care is good too, so there should be a clear difference. Shouldn’t there?

    • Thanks Debbie,
      Yes most of the modern world looks to the Netherlands as the most wonderful place to work as a midwife. I know it is a dream of mine to get the chance to work there, maybe in the next few years!
      It is interesting why there is a big drop off with BF rates in the Netherlands from 6 weeks. How long does the kraamverzorgster care for the mother? Is it just in the first week or two or up until 6-8 weeks postpartum? The fact that all mothers get 4-8 hours support each day is amazing, how wonderful.
      The rates of breastfeeding initiation and duration rates can be seen here
      http://www.lalecheleague.org/cbi/bfstats03.html
      https://apps.who.int/nut/db_bfd.htm

  7. Wonderful, wonderful post, thank you! 🙂

  8. A great article.
    My baby is 6 weeks old and we are still struggling to establish a milk supply.
    Unfortunately i had major haemmorraging after birth and had to be separated for a couple of hours while they took me to theatre to be fixed up. Only got 15 minutes after she arrived before they handed her to hubby while they worked on me.
    The next day i was pretty out of it most of the day so missed the initial bonding period straight up.

    Then I wasn’t told that the hospital had pumps that would help me express to build up my supply until the night before I went home. By then I was going insane because bub wasnt getting enough milk and was getting ready to just go on formula.

    • Thanks for your comment Megan. Unfortunately we hear this kind of story far to frequently. Enjoy as many cuddles and bath times together from now on, it’s never too late to bond with your baby. There is no such thing a spoiling your baby with love!
      I hope Megan you are seeking help for your supply issues with a good child health nurse or lactation consultant. If you are in Australia or NZ you can find an LC in your area through http://www.lcanz.com or if the US http://www.ilca.org. If in the UK http://www.lcgb.org.

  9. lovely article, particularly re the impacts of post-birth trauma and subsequent maternal exhaustion. Despite many good things here in New Zealand I am surprised to see a large hungry newborn baby whose mother is suffering exhaustion and fluid retention being fed only four hourly for most of the first week.

  10. Fantastic read, and agree totally

  11. thanks for explanation
    i will try to give all the best for my baby
    🙂

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