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Breastfeeding: state of the art

10 June, 2008

Breastfeeding: state of the art

This is areport of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Tuesday 24 February 2004. The meeting was chaired by Dr Elvidina Adamson- Macedo, perinatal psychologist at the University of Wolverhampton.


This is areport of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Tuesday 24 February 2004. The meeting was chaired by Dr Elvidina Adamson- Macedo, perinatal psychologist at the University of Wolverhampton. 


Midwives magazine: July 2004


Enabling wornen to breastfeed - the evidence trorn systernatic reviews

Professor Mary Renfrew, midwife and director of the Mother and Infant Research Unit at Leeds Infirmary

Breastfeeding is a fundamentally important public health issue, and an important one for mothers, babies and families. Recent policy changes in the UK and internationally support work towards increasing breastfeeding initiation rates, and encouraging exclusive breastfeeding for six months. The government's very difficult target is to increase breastfeeding by 2% annually among women from deprived groups, where rates are low. The challenge to mothers and healthcare practitioners is very hard to meet.


This paper will summarise the results of a series of systematic reviews of clinical and health promotion interventions, examining ways of increasing breastfeeding initiation and duration, especially among families from low-income groups. Suggestions for coordinated action at national and local levels will be made, based on this evidence. 1t is dear that breastfeeding is an important and effective intervention with multiple benefits: less mortality in premature babies; less gastroenteritis, atopic disease, respiratory disease, urinary tract infection, otitis media, and hospitalisation in infancy. Other risks are reduced: diabetes and obesity in childhood; adult disease, including cardiovascular disease and Crohn's disease. 1Q is also increased, and there are benefits for maternal health and the mother-baby relationship.


Much research in this area is flawed, though improving recently. Nevertheless, if breastfeeding were a drug, the drug companies would be dimbing over themselves to get it on to the market. The problem is that in the UK, breastfeeding rates are low, and lowest among families living in socially- and materially deprived circumstances.


There are many reasons for this, involving psychosocial factors, continuation of practices in hospital that make breastfeeding difficult, and a lack of basic education among health professionals working in hospital and community settings. Lack of public support is also a major issue. Though easy physiologically, breastfeeding is culturally difficult, more so in lower socio-economic groups. Less than half the babies living in the most deprived conditions and experiencing the poorest health status are likely to be breastfed at all. Less than a quarter of those breastfed continue to do so for more than four months, and supplements are introduced early. 


To address inequality the number of women breastfeeding in social classes four and five needs to be doubled, for initiation and for continuation at four months, to achieve the same rates as higher social class groups and dose the gap. 1nappropriate and harmful hospital practices and routines make breastfeeding difficult. So does lack of confidence and experience in mothers, health professionals, and families, with consequent lack of support. Early return to employment is the norm, with little support in the workplace. Society is not breastfeeding friendly; there is a bottle- feeding culture among some groups.


As part of a larger study Looking at infant feeding today, focus groups with pregnant women and men living in socially- and materially-deprived circumstances, expressed their perceptions of the disadvantages of breastfeeding and of related physical problems such as pain. Few were aware of the disadvantages of artificial feeding, and breastfeeding in public was a predominant issue: there was an underlying lack of self-confidence. However, research among low-income groups is very limited. There are problems of literacy, language and culture, and poor response to postal questionnaires - these are groups that move house frequently.


The partner of a pregnant woman, said: 'I just think that breastfeeding gives you breast cancer, no one ever told us the good points, so they haven't said it's good. 'I think a lot of young mothers won't breastfeed because the reaction is - "You're lazy,you don't want to be getting up and making bottles at night, it's easier to grab the baby and put the baby on your breast than to go downstairs and warm the bottle up.''' Breastfeeding in public is a huge concern for women, theysee this as providing voyeuristic pleasure for men who are not their partners, and many men have confirmed this. It is particularly difficult for women travelling on public transport, but it can also be a problem for women breastfeeding in front of others in their own hornes.


What follows is evidence-based information on initiation and maintenance of breastfeeding. Peer support programmes in the antenatal and postnatal periods, combined with local media campaigns, are especially useful for women on low incomes who have expressed a desire to breastfeed, especially when delivered by a trained counsellor who is herself a locally resident mother who has breastfed.


Also effective are mother-to-mother support groups, led by a trained counsellor, sometimes with a health visitor, in women's hornes or a community centre. Small-group informal health education sessions increase initiation rates among women from all income and different ethnic groups. Modest payments in cash or in kind (for example, provision of breast pads or bus fares), and involvement of women's partners, sisters or mothers in health education activities, increase participation in group sessions (Renfrew et al, 2000).


Continuous support in labour (Hodnett, 2004), early dose contact - which is most effective, and not specific to women on low incomes - and the baby rooming-in, promote maintenance of breastfeeding. Vital is accurate advice and care in regard to positioning, unrestricted contact and problems, and here the good advice of health professionals is crucial; unfortunately many are not well trained to provide such advice. Face-to-face support, lay or professional, is best, though telephone support can also be effective (Sikorski et al, 2004; Fairbank et al, 2000). Harmful practices such as supplementation, discharge packs (Donnelly et al, 2004), and restricted contact must be avoided.


A multifaceted approach, otherwise the Baby-Friendly initiative, works - peer support in combination with health education, media programmes and/or changes to the healthcare sector, including training of health professionals and changes in government and hospitalpolicies; all these were well done in Scandinavia.


What does not work? Literature or leaflets alone. Staff training, unless it is part of a multifaceted approach as above. National media campaigns increase breastfeeding levels among women on high incomes with no effect on those with lower incomes.


Desirable policy developments are government guidance on good practice as incorporated by the National Institute for Clinical Excellence, the NHS National Service Framework, and the Commission for Healthcare Audit and Inspection. Agreed targets, with appropriate routine monitoring, as with immunisation, are helpful; so too is Healthy Start, where support for breastfeeding is expected to be an improvement on the present welfare food scherne. So is the development of community-based peer and professional resources, Sure Start and public facilities for breastfeeding. Nationally, we need to implement rooming-in fully, to remove harmful practices, implement evidence-based care in hospitals, and support the Baby-Friendly initiative in hospital and the community (Protheroe et al, 2003). Breastfeeding training for all health professionals must be reviewed, ensuring that it is evidence-based and appropriate for all groups. Pre-registration education and mandatory updating, presently absent from the curriculum, are urgently needed.


Ideas for action locally include the national linking of breastfeeding coordinators to primary care trusts (PCTs) and hospitals, inequalities initiatives such as Sure Start and the Health Action Zone initiative; the recruitment and training of local mothers as paid counsellors; incentives for mothers to support participation in groups, with pumps (Snowden et al, 2004) and breast pads; reviews of health promotion; parent activities to ensure deliveryof appropriate information, and support for local staff training.


The objective is successful breastfeeding for all, enabling mothers and babies to enjoy their breastfeeding relationships without the traumas to which I have alluded. They and their families need access to activities throughout pregnancy, birth and after, involving policy-makers and educators.


Developing local breastfeeding strategies for PCTs: use of research evidence

Professor Louise Wallace, professor of psychology and health, director of Health Services Research Centre at Coventry University

 The importance of breastfeeding to achieving a wide range of public health benefits to children and mothers has been long established. The new NHS target for PCTs to increase breastfeeding initiation by 2% per annum in those least likely to breastfeed has put the spotlight of NHS management on breastfeeding research, and on those practitioners whose skills are needed to turn evidence in to practice.


Results of research on midwifery support for breastfeeding mothers are used here to highlight areas for action. Given the importance of the skills and knowledge of staff and lay supporters who assist mothers and babies, development of new approaches to training and assessment are described. The approach to consultancy with local PCTs is explained. Using a social-marketing approach, key stakeholders' views can be harnessed for effective local action.


So we have the 2% per annum increase in the breastfeeding target for PCTs from April 2004, but no national breastfeeding strategy, though one is expected for England. There are huge known public health benefits, and breastfeeding sits within the government's inequalities priorities, since those least likely to breastfeed are also the most disadvantaged in other ways. National survey data shows that mixed feeding within days or weeks is the norm, and less than 10% are breastfeeding exclusively at six months as recommended by the World Health Organization. Social class and education differences favour the most advantaged.


The information ihave on where we are now is based on my experience with four Midlands PCTs, where my role has been as a researcher with data on local services, and ihave a familiarity with published research, which busy workers in the field may have little time to access. lama non-executive director of a PCT with a lead rolein public health, and consultant to the public health director of another PCT.


The definitions of breastfeeding patterns shows marked variation between clinical notes and diaries kept by the mothers. These reveal a range between exclusive breastfeeding and mixed feeding; precise definitions can provide accurate data, whereas loose definitions are likely to lead to definition drift, tending erroneously to favour exclusive breastfeeding.


Enquiry into the antenatal discussion of breastfeeding showed that 97% of primigravidae attended antenatal checks and 85% attended antenatal classes; however 30% reported that they could recall no discussion of breastfeeding - serious examples of missed opportunities. In a hospital trial of the help received by breastfeeding mothers, 85% reported needing help with the first feed and 75% needed help with later feeds also. Around 55% always got the help they needed, but the level of help available varied considerably, with 1%receiving no help at all, despite a requirement that the midwives should help all the mothers.


Predictors of breastfeeding at six weeks were found in the 'Breastfeeding Best Start' randomised-controlled trial: mothers who had been breastfed themselves, and early feeding after the birth (Inch et al, 2003, 2004). Failure to feed for six weeks was predicted ifthe baby was even slightly unwell after the birth, or was given other than the mother's milk at the breast in hospital or at horne (30.3% of the mother's expressed breastmilk, 9.5% donated breastmilk and 60.2% used formula) or if the mother did not receive the help she needed (see Graph 1).


Antenatal advice is often lacking. Even in a trial of midwifery care, breastfeeding was not always initiated in the delivery suite; help received is often insufficient. Supplementation of 25% of so-called breastfed babies reduces the likelihood of maintained breastfeeding.


The training of 104 midwives was assessed before and after four hours of training on hands-off positioning and attachment care, and compared with the knowledge of student midwives who did not receive the same training. Although the midwives' training was effective there was great variability in their basic knowledge, which was no better than that of the students.


As first steps in achieving better breastfeeding numbers, turn to the Baby-Friendly initiative, irnprove training and reduce poor hospital and community health practices. The hard-to-reach mothers need lay, peer and professional support ante- and postnatally. Individual, group, buddying and phone support should be available, and occasional radio or newspaper stories about 'breast is best' are helpful.


But why is doing all this not enough?

Breastfeeding is championed by frontline staff with limited resources and influence. It is complex, and influenced by social, employment and environmental factors that PCTs cannot control!. Big shifts in voluntary behaviour, such as breastfeeding, require many and consistent messages and behavioural incentives for staff as weil as mothers. I recommend a social-marketing approach (Lindberger et al, 2000).


Data is needed to identify the target group: is it all pregnant women and new mothers, or deprived sub-groups? This requires audit and prospective data, with agreed definitions and routine data collection at all key times. Interview women and their partners about support they need, which will differ significantly for example, between white British and immigrant groups. Assemble new or existing data such as patient surveys, comments collected at antenatal classes, and from feeding diaries and focus groups. Discover the views of staff on their training needs, and make a formal assessment of their skills. Develop a strategy with senior and expert buy-in. Establish a powerful steering group with representatives from the PCT, public health, Sure Start and employers, for example the Chamber of Commerce. Involve a GP champion, a breastfeeding adviser, and the heads of midwifery and health visiting services. Set up connections to young people, their education and early employment, and to mothers and other organisations such as the National Childbirth Trust and the La Leche League; to academics and experts on infant nutrition, public health evidence, and communications.


Mothers should not just hear 'breast is best', but that breastfeeding is convenient and aids bonding, based on the views of local cultural groups and on the aim to achieve pain-free breastfeeding and expression. Staff must be equipped with effective breastfeeding skills, built on a training needs analysis and shaped to the level required. Typically, this would be 18 hours for local trainers (known to be effective), four-hour workshops for midwives and health visitors, workbook and video for support staff, and video for GP receptionists. Ensure that the message is consistent across strategies, for example in teenage pregnancy work, homelessness, and prisons.


Messages to women should reduce barriers, highlight benefits, build up self-efficacy, the confidence to seek support, and build skills to achieve competence in positioning, attachment, expression, and demand feeding, based on psychosocial cognition theories. The messageneeds also to inform health promotion, personal and social education in schools, school nursing, ante- and postnatal care, health visiting, and support groups. By the use of peers and highprofile champions in the media, social approval is boosted. Standards have to be achieved, practiees reviewed, training needs established and training and ongoing development provided in all the affected services.


Regular audit should be instituted on data quality and definitions, and on manuals about supplementation, skin-to-skin contact, and policy. General and breastfeeding leaflets have to be updated and new materials produced, for example policy guides and health service leaflets on breastfeeding mothers at work. Target employers, for example the PCT through the Department of Health's 'Improving working lives' initiative, and employers' forums, with media coverage.


Adjustments can be made in data quality, training needs, and messages to mothers using the feeding diaries of new mothers, data from health visitor records, the suggestions board in the Baby Cafe, the views of the Patients' Council, and those of maternity liaison comrnittees. Skills can be evaluated using the methods of project management and advice from research departments. Examples are the Coventry University Breastfeeding Assessment (under development) and assessment of the impact of media campaigns by coverage.


Breastfeeding strategies should not be documents, but live plans developed by key players and involving power brokers in the NHS and the local community at all stages. Existing information sources must be used to develop unique tailored approach es, which build on and contribute to research evidence of what works. Now is the time to speak to PCTs, who, having targets to achieve, are very grateful for advice from frontline workers.


Biological nurturing - a new approach to breastfeeding


Philippa Parrett, breastfeeding counsellor, trainee tutor and lactation consultant, at the National Childbirth Trust, and Suzanne Colson, lactation midwife at Bast Kent Hospitals NHS Trust. '


The established approach in our society is to think of birthing as something done while lying down. We try to give a birthing woman freedom to find the right position for her own needs and comfort' (Odent, 1984).


British mothers are some of the least likely in Europe to sustain breastfeeding, despite almost 20 years of public health strategies to promote the biological choice. The established approach suggests a fixed system of verbal instruction, with midwives getting mothers to position themselves (back upright, at right angles to lap) to attach the baby onto the breast correctly. Knowledgeable support may be crucial in overcoming common problems leading to unintentional early weaning.


Biological nurturing is designed to facilitate breastfeeding, with the aim first to avoid difficulties, but also as a problem-solving strategy. Parents are shown a video and given a booklet illustrating positions where newborn babies attach themselves to the breast; mothers are encouraged to adopt any position where they feel comfortable. Photographs illustrate how to place the baby prone against a body contour. Midwives are trained to assess milk transfer using their observations of hormonal complexion, nutritional physiology and counselling techniques.


Research has shown that biological nurturing can support mothers who might otherwise give up breastfeeding in the first two postnatal weeks, and this applies, importantly, to preterm and small for gestational age (SGA) babies. The theoretical framework, introducing freedom of maternal positions, a range of feeding states, applied anatomy and nutritional physiology, comprises kangaroo mother care, skin to skin (Anderson, 1999), infant behaviours (Widstrom, 1987; Righard andAlade, 1990) and anatomy and physiology (Howie, 1985; Woolridge, 1986; Nissen at al, 1996; Uvnas-Moberg, 1996; Odent, 1999).


Clinical evidence incIudes the Community Access to Child Health (CATCH) Department of Health practice development project, and observations of some healthy preterm and SGA babies being excIusively breastfed from birth (De Rooy and Hawdon, 2002; Coison, De Rooy and Hawdon, 2003). Oxytocin modifies sexual, maternal and social behaviours; it has an antistress effect, each suckIing episode being followed bya fall in blood press ure. Breastfeeding mothers are calmer, correlating with oxytocin concentrations (Uvnas-Moberg, 1998). Maternal concentrations of oxytocin are higher irnrnediately after birth than at any time during labour (Uvnas-Moberg, 1999). An increase in oxytocin release on the second day postpartum is associated with longer duration ofbreastfeeding (Nissen et al, 1996). Prolactin directs maternallove toward the baby (Odent, 1999); its blood levels peak within 30 to 45 minutes of the start of a breastfeed (Howie, 1985). Mothers giving birth by caesarean section lack a significant rise in prolactin levels at 20 to 30 minutes from the start of a breastfeed (Nissen et al, 1996).


Oxytocin has been known as the love hormone for some time; it promotes sexual and maternal behaviours, aside from its mechanical actions in the birth process. Under the influence of oxytocin, mothers become contented, disconnected from their environment, develop a facial flush, and the nipples become erect. A mother in this state can easily be disturbed by inappropriate speech, or by a midwife coming on duty and introducing herself. Of course, the state can be recovered. (A series of video examples demonstrated ideal biological nurturing positions, as when a mother lies supine, with her upper back and head supported bya pillow; a baby is seen to latch onto the breast although asleep. Inefficient or painful latching on can be improved by drawing the baby's lower lip down slightly).


A simple definition of nurturing is the way mothers show their love for their babies. In biological nurturing, we invite mothers to place their babies with as much skin-to-skin contact as they wish, following the contours of their bodies. They are encouraged to cuddle their babies for as often and as long as they want, particularly in the first three days of life. The mothers and babies can be lightly dressed, fathers too can take part. An important component ofbiological nurturing is the midwife's hands-off assessment. The baby is given the breast and latches on; she may fall asleep while latched on, and remains in a drowsy state while still feeding. Why would anyone hold a sleeping baby to the breast? Because they latch on and feed, and when they come off spontaneously, the breast is no longer engorged.


Breastfeeding promotes relaxation, rather than the other way about. A mother in this oxytocic state on the second day after her baby's birth is more likely than not to continue breastfeeding.


For further information on this presentation, please contact Suzanne Coison by email:sdc8@canterbury.ac.uk




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