Midwives Helping Mothers to Breastfeed: Food for Thought and Action
In 1990, breastfeeding was on the decline, and only 52% of U.S. mothers initiated nursing. Of these, only 18% continued to breastfeed until their babies were 6 months old. The Healthy People 2000 campaign set goals that 75% of new mothers would initiate breastfeeding and 50% would continue nursing for at least 6 months (1). Those objectives also focused on the dramatic differences in breastfeeding among population subgroups: in 1990, breastfeeding was initiated by 23% of black mothers, 48% of Hispanic mothers, 58% of white mothers, and 35% of low-income mothers (1). Current national data, which reflect breastfeeding rates through 1998, indicate that the Year 2000 breastfeeding objectives will not be met; thus, these goals have already been enfolded into the Healthy People 2010 objectives (2). Nevertheless, some progress has been made, and breastfeeding has increased during the 1990s. In 1998, 64% of mothers initiated breastfeeding, and 29% were still nursing at 6 months postpartum.
Unfortunately, racial and socioeconomic disparities in breastfeeding rates have continued. Breastfeeding mothers are still more likely to be white or Hispanic, older, college educated, of higher income, and living in the mountain or Pacific states. It is encouraging, however, to see that breastfeeding has increased the most among groups whose rates were previously the lowest: mothers who are young, black, less educated, of low income, and living in the South Atlantic states (3). In 1998, 45% of black mothers, 66% of Hispanic mothers, 68% of white mothers, and 52% of low-income mothers initiated breastfeeding.
Health care providers are concerned about the low rates of breastfeeding in the general population and among vulnerable women, in particular; indeed, many professional organizations, including the American College of Nurse-Midwives, have issued position statements in support of breastfeeding (4). Nevertheless, research findings have repeatedly shown that mothers generally do not regard health professionals and hospitals as important sources of breastfeeding information and support (5–7). Furthermore, there is some evidence that low-income women, who may feel judged and misunderstood by health professionals, may consequently have misgivings about health promotion messages they hear in the prenatal clinic (8). For these reasons, this special issue of the Journal of Midwifery & Women's Health (JMWH) raises some important questions concerning the midwife's role in breastfeeding care:
• With the field of lactation management expanding so rapidly, how can midwives maintain up-to-date knowledge and skills?
• Can midwives work more collaboratively with other breastfeeding specialists to benefit nursing mothers?
• How can midwives promote and support breastfeeding most effectively within the health system and in the community?
• What special barriers to breastfeeding are faced by low-income and ethnic minority women, and how can midwives help address them?
BREASTFEEDING KNOWLEDGE AND SKILLS
Although very few studies have surveyed groups of health professionals about breastfeeding knowledge, nurse-midwives have earned high marks in such comparisons (9). One area in which midwives make a strong contribution to breastfeeding promotion is prenatal care. Discussions about infant feeding plans should begin early in pregnancy and happen often because the woman's thinking and concerns may evolve and change. The midwife should convey enthusiasm and provide information without foreclosing possibilities: “What questions do you have about breastfeeding?” is likely to lead to a better exchange than “Are you planning to breastfeed or bottle feed?” Not only women who are undecided, but also those who plan to breastfeed as well as those who have breastfed before may want new information and an opportunity to express their feelings and concerns. During prenatal counseling, midwives can promote realistic expectations by acknowledging the barriers to breastfeeding that exist in society and the commitment that is needed to overcome them. Honest discussion of difficult issues like breastfeeding in public, reactions of family and friends, and combining breastfeeding and working can help mothers prepare for the realities they will face when integrating breastfeeding into their daily lives.
The art and science of breastfeeding are ever-evolving, and midwives who do not make an effort to stay current may find themselves basing practice on outdated information. Examples of issues on which recommendations have changed over the past decade include prenatal preparation for breastfeeding, alcohol consumption by nursing mothers, and the recommended duration of breastfeeding. Guidelines for assessing and supporting lactation have been developed (10,11) that include recognizing infant feeding cues, helping the nursing dyad with latching on and positioning, suck assessment, establishing milk production, monitoring the frequency and duration of feedings, and dealing with common problems, such as engorgement, sore nipples, and one-breast preference. Current information on these and many other breastfeeding topics can be acquired from conferences, textbooks, videos, websites, and lactation specialist colleagues. Midwives who have the technical skills to assess and teach breastfeeding basics can make a critical contribution to a positive nursing relationship and the early resolution of potential problems. If the mother is agreeable, it is extremely helpful to involve her support people in these early efforts. Her mother or grandmother may have learned very different information about infant feeding than what the midwife is teaching; if past information can be discussed and updated, there will be more likelihood of the midwife, family, and friends working together to support the mother. Like so much else about midwifery care, breastfeeding support is most effectively provided in the context of a trusting relationship, and in a manner that builds the mother's self-confidence and develops her problem-solving abilities.
MIDWIVES AND BREASTFEEDING SPECIALISTS
Not too many years ago, the midwife was likely to be the most knowledgeable member of the health care team about breastfeeding. Today, an increasing number of intensively trained lactation consultants are employed by hospitals to carry out such activities as making breastfeeding rounds, managing a telephone “warm line,” and providing intensive support to nursing mothers of infants in the special care nurseries. Does this mean that the busy midwife can now step back from her role as a breastfeeding care provider? Every lactation consultant to whom this question was posed answered a resounding “NO!” Several noted with concern that some health professionals disengage from breastfeeding care if they think the lactation consultant will provide it. Ideally, the midwife will provide basic breastfeeding care for the women whose birth she attends, seeking help with problems and special situations from the lactation consultant. When lactation consultants are freed from providing “routine” breastfeeding care for all nursing mothers, they may be able to expand their role into vital, but often-neglected areas, including community outreach and work in the prenatal and postpartum outpatient settings. Unfortunately, prenatal breastfeeding classes and outpatient services by lactation consultants are very often denied reimbursement by health insurance agencies, and so are less accessible to low-income mothers. Lactation consultants are an important resource for midwives and other breastfeeding care providers, and are often more than willing to make formal and informal presentations on aspects of lactation management for midwifery, nursing, and medical audiences.
PROMOTING BREASTFEEDING IN THE HOSPITAL, HEALTH SYSTEM, AND COMMUNITY
Midwives are ideal advocates for breastfeeding promotion within hospitals and the health care system. They have been instrumental in forming institutional breastfeeding committees and have supported the Baby Friendly Hospital Initiative that endorses policies such as 24-hour rooming in, follow-up care for nursing mothers, and the elimination of formula discharge packs for mothers and free artificial milk for hospitals (12). Because midwives provide continuity of care, they can also be instrumental in coordinating breastfeeding care between the outpatient and inpatient settings. Current research has identified a detrimental impact of certain routine labor and delivery interventions on breastfeeding, including induction/stimulation of labor (13) and the use of anesthesia/analgesia (14,15). Midwives can discuss these findings with women, obstetricians, anesthesiologists, and nurses to increase their awareness of the health consequences of labor management practices which they may regard as innocuous.
On the community level and within society at large, midwives can become involved in lobbying for expanded maternity leaves, workplace support of breastfeeding, and universal and comprehensive health insurance coverage, including reimbursement for lactation services and pump rentals. When health professionals bemoan the low breastfeeding rates in the United States compared with other developed nations, they must remember that European countries provide long and generous maternity leaves and extensive health service benefits as a matter of national policy. When this culture's conflicted attitudes about breasts, infant feeding, and sexuality are combined with the barriers found in the health system and workplaces, obstacles to breastfeeding are created for American mothers that are unique in the industrialized world.
PROMOTING BREASTFEEDING AMONG VULNERABLE MOTHERS
In order to effectively encourage and support breastfeeding among low-income and ethnic minority mothers, midwives must work to understand and address the social and cultural factors that affect infant feeding in their communities. For example, there is some evidence that modesty about exposing the breasts in public plays an especially significant role in discouraging African American women from breastfeeding. If so, this factor should be carefully considered and discussed during prenatal breastfeeding counseling, and information on nursing with discretion should be emphasized.
Breastfeeding in the workplace is an issue that is often framed differently for lower- and upper-income women. Women who work in low-paying jobs are much less likely to be granted the privacy and flexibility they need to pump their breasts to maintain milk supply. The midwife who individualizes counseling and follows up with employers in order to request time, space, and privacy for pumping breaks may reap benefits for individual mothers and all women in the future.
Immigrant women usually come from a strong breastfeeding tradition, but many abandon the ways of their homeland because they find nursing incompatible with life in the United States. Midwives should learn about the culture and barriers to breastfeeding faced by the immigrant mothers they care for and support healthful traditional practices. When language barriers exist, it is immensely helpful to provide breastfeeding literature and care in the mother's tongue, perhaps by means of a health-system-sponsored doula.
In recent years, hospitals, health departments, the La Leche League, and the Special Supplemental Foods Program for Women, Infants and Children (WIC) have sponsored innovative breastfeeding promotion programs for low income women. One especially promising approach has been the preparation of Breastfeeding Peer Counselors or Doulas—community women who receive training about breastfeeding management and who support and counsel mothers in their neighborhoods and health centers. In large and fragmented health facilities, it is, unfortunately, all too easy for a midwife who is working hard to promote breastfeeding to be unaware of innovative programs that are close by and available to patients through WIC or other special programs. When efforts are made to seek out and work with community breastfeeding support programs, both midwives and their clients are enriched.
JMWH BREASTFEEDING ISSUE
This issue of JMWH is devoted entirely to a Home Study Program on Lactation Issues for the New Millennium, and it contains many interesting, thought-provoking manuscripts. Hellings and Howe report on the first statewide survey of the breastfeeding knowledge of nurse practitioners and nurse-midwives and compare their results with the first national breastfeeding knowledge survey of physicians. Clinical aspects of lactation management are the focus of four articles: Auerbach's review of the effect of hospital practices on breastfeeding; Tait's article on nipple pain; the study of breastfeeding and sexuality by Avery et al; and Black and Hylander's overview of breastfeeding issues for the high-risk infant. Zinn offers both clinical insights and a policy perspective on the issue of breastfeeding and employment. The excellent review of breastfeeding duration among low-income mothers by Milligan et al provides a context for the qualitative studies by Raisler (successful breastfeeding among WIC recipients) and Rossiter (Vietnamese immigrants' perceptions of breastfeeding care). It is hoped that these research studies, clinically focused articles, and literature reviews will inform and support midwives, who are natural leaders in breastfeeding promotion and care.