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By Rebecca H. Allen, MD, MPH
Assistant Professor, Department of Obstetrics and Gynecology,
Warren Alpert Medical School of Brown University,
Women and Infants Hospital, Providence, RI
Dr. Allen reports no financial relationships relevant to this field of study.
Synopsis: This review outlines steps that OB/GYNs can take to support their patients who desire to breastfeed. Certain
interventions — such as skin-to-skin care at birth, rooming-in for mother and infant postpartum, and avoiding formula feeding — are beneficial for initiating breastfeeding. OB/GYNs can also help women maintain breastfeeding after they leave the hospital by managing the perception of low milk supply and any complications.
Source: Stuebe AM. Enabling women to achieve their breastfeeding goals. Obstet Gynecol 2014;123:643-652.
This is a review of breastfeeding and how obstetrician-gynecologists can support women who desire to breastfeed at different stages: antepartum, intrapartum, and postpartum. Breastfeeding exclusively to 6 months of infant life is recommended by most major medical organizations, and the American Academy of Pediatrics encourages breastfeeding to at least 1 year. The author recommends asking an open-ended question, "What have you heard about breastfeeding?" Ideally, this is asked early in pregnancy, given that most women have already decided then how to feed their infant. Intrapartum care is one of the most important pieces to facilitate breastfeeding initiation. A national program, "The Baby-Friendly Hospital Initiative" is helping hospitals implement 10 practices that promote breastfeeding. A few key interventions are skin-to-skin care and breastfeeding within 1 hour at birth, both for vaginal delivery and cesarean delivery patients; no pacifiers, except for analgesic benefit during circumcision or other procedures; and having mothers and infants room together postpartum. In essence, the newborn nursery should be empty except for the few infants who need extra observation. Other steps include having a written supportive breastfeeding policy for the hospital, training health care staff in the skills necessary to help women breastfeed (including providers and nurses), giving breastfeeding newborns only breast milk (unless medically indicated), teaching women how to breastfeed, and referring women to community support services postpartum. Not surprisingly, the "unmedicated spontaneous vaginal birth" is associated with the best breastfeeding outcomes, since cesarean delivery, epidural anesthesia, and parenteral narcotics have been associated with delayed lactogenesis and breastfeeding difficulties.
Postpartum, the author of this published article has a negative view on the effects of hormonal contraception on breastfeeding and recommends that women use the lactational amenorrhea method of contraception if they succeed at exclusively breastfeeding. At postpartum visits, this author suggests that OB/GYNs can assess breastfeeding by reviewing milk letdown, infant latch, and the frequency of feeds. Collaborating with the infant’s pediatrician and an International Board Certified Lactation Consultant is recommended for any difficulties. Given that postpartum depression and anxiety can impact breastfeeding, the author recommends that providers screen for these issues and use the selective serotonin reuptake inhibitor, sertraline, if needed for therapy, since it is safe with breastfeeding. The perception of low milk supply is often a cause of premature weaning, so it can be helpful to educate the patient and her family that feeding every 1-2 hours is normal for infants. There is no good evidence that galactogogues are safe and facilitate milk supply.
The rate of breastfeeding initiation over time in the United States has fluctuated from 70% in the early 1900s, to 22% in the 1970s, and back up to 77% in 2010. In 2013, the proportion of women with any breastfeeding compared to exclusive breastfeeding at 6 months was 49% and 16.4%, respectively.1 There is no doubt that breastfeeding is beneficial in many ways to the health and well being of mothers and infants, as well as providing an environmentally friendly and "free" food for infants. However, whether breastfeeding is causally related to the many health benefits its supporters claim, is still up for debate, even though it may be heresy to say so.2 After all, there are not likely to be many randomized, controlled trials on the subject and observational epidemiology has its limitations, especially confounding factors. As Colen et al note, "Compared to bottle-fed infants, breastfed infants are significantly more likely to be white, be born into families with above average incomes, have parents with advanced educational attainment, maintain easier access to health care services, and live in safer neighborhoods with lower levels of environmental toxins."2 It is difficult to isolate the effect of breastfeeding given these circumstances. Nevertheless, increasing breastfeeding rates has become a national policy goal, and hospitals and providers can play a part, as this article reviews. I have firsthand knowledge of the The Baby-Friendly Hospital Initiative as my hospital is currently undergoing the process to become Baby-Friendly Certified.3 I sometimes wonder if that means we were "Baby-Unfriendly" before!
This article outlines certain practices that providers and hospitals can take to encourage breastfeeding. This is certainly admirable and we should support mothers who want to breastfeed, but what about those who do not or cannot? I feel that the pendulum toward breastfeeding and against formula has swung so far that women now feel guilty and like a failure if they cannot exclusively breastfeed their infants or have difficulties establishing a milk supply. After all, as Colen et al point out, "Total commitment to 6 months of exclusive breastfeeding is a very high expectation of mothers, especially in an era when a majority of women work outside the home, often in jobs with little flexibility and limited maternity leave, and in a country that offers few family policies to support newborns or their mothers."2
Some of the intrapartum and postpartum steps to obtain Baby-Friendly Hospital status and support breastfeeding initiation make perfect sense. For example, skin-to-skin care and letting the infant latch within an hour after birth is great bonding for the mother and child. In addition, women who have to be separated from their infant (e.g., due to prematurity) can be taught how to pump milk to establish their milk supply. The rooming-in idea stems from the fact that infants normally feed every 1-2 hours so the infant needs to be in the same postpartum room as the mother, not down the hall in the nursery. For most women and families, this is manageable and our patients are now advised antepartum what to expect about rooming in during their hospital stay. Some hospitals have even closed their newborn nurseries! Nevertheless, the obstetrician in me, being very protective of my patients, feels that women who have been through arduous labors or cesarean deliveries with complications, need to be able to rest and heal. They may not have a willing partner who can take care of the infant in their hospital room while they sleep. In these situations, I think the postpartum nurses, can and should, take care of the infant. I have been told that the goal is 80% rooming-in for Baby Friendly Hospital status and that exceptions can be made. My larger issue with the Baby Friendly Hospital designation is that while it may help initiate breastfeeding, maintenance is another matter entirely. Once the patient goes home, unless they can afford or have insurance coverage for lactation consultants, they are often on their own, figuring out how to maintain breastfeeding. Certainly, unpaid maternity leave and having to go back to work 4 or 6 weeks postpartum does not help. I feel that until we, as a society, begin to value women and infants by providing paid maternity and paternity leaves, our national breastfeeding goal will go unfulfilled. While the Affordable Care Act now covers lactation counseling and costs for renting breastfeeding equipment, that does not solve other societal barriers.4 For my patients who are having difficulty breastfeeding, I certainly refer them to lactation consultants and support them, but I also validate how difficult it can be and reassure them that they are not bad mothers if they cannot continue.
Finally, I would challenge the author of this review on the effect of hormonal contraception on breastfeeding. I agree that we don’t have enough data to say that progestin-only methods absolutely do not affect breastfeeding initiation or maintenance when given less than 6 weeks postpartum. But at the same time, as a physiologic process, so many factors affect breastfeeding (mode of delivery, medications, stress, anatomy, the infant, etc.) that isolating hormonal contraception as the main culprit seems dubious. This is especially important in populations with high unintended and repeat pregnancy rates. These women and their current children might be better served by highly effective contraception and less breastfeeding than having another child within 1 year of their delivery. For many women, the idea that they will be able to breastfeed exclusively and use lactational amenorrhea for contraception is a fantasy. We often administer depot medroxyprogesterone acetate or the etonogestrel implant to our patients before they are discharged postpartum so that they can be protected against rapid repeat pregnancy, and this is supported by the United States Medical Eligibility Criteria for Contraceptive Use.5