Specific nurse interventions to support breastfeeding will be better understood within the context of the concept's antecedents and consequences. The antecedents of breastfeeding are categorized as maternal anatomy and physiology, child anatomy and physiology, closeness, maternal internal resources, and maternal external resources. Nurses can support the antecedents or facilitators when present. In cases where mother-child dyads lack the antecedents, the nurse can help mother and child compensate for actual or potential challenges.
Maternal and Child Anatomy and Physiology
The lactating woman is the source of milk for the child in the breastfeeding relationship. The physiological process of producing and delivering the milk, as well as the physical anatomy of the mother that the infant attaches, is essential to breastfeeding success (Geddes, 2007; Mulder, 2006). The complex details of lactation are beyond the scope of this concept analysis, however, the distinction between breastfeeding and breast milk feeding will be made.
Breastfeeding is the direct feeding of breast milk to a child at a woman's lactating breast. Breastfeeding is a mutual interaction that has implications for both the woman and child in terms of the process of breastfeeding and benefits of breastfeeding (Abrahams & Labbok, 2011). For example, the child's removal of breast milk at the breast through breastfeeding regulates the woman's supply based on the child's need (Kent, Prime, & Garbin, 2012).
In contrast to breastfeeding, breast milk feeding is an asynchronous process that involves the removal of breast milk from a woman's lactating breast by means other than a child and then consumption of the breast milk by the child via means other than breastfeeding. A number of variables are introduced with breast milk feeding that can influence the breast milk and the benefits of breastfeeding. For example, some antioxidants in breast milk are reduced with freezing particularly when stored for long periods of time (Silvestre et al., 2010). The method breast milk is provided to the child is another key variable since the process of breastfeeding at the breast is very different from the mechanics of bottle feeding (Abrahams & Labbok, 2011).
Breastfeeding is optimal because of the nutrient of breast milk and the process of feeding at the breast (Abrahams & Labbok, 2011). Nurses need to understand and support the natural anatomical and physiological process of breastfeeding. When direct breastfeeding is not possible, breast milk feeding is a better alternative to various types of artificial feeding.
The physical closeness between a mother and child is a powerful antecedent to optimal breastfeeding practices. Skin-to-skin contact after birth is associated with improved breastfeeding initiation, whereas separation at that critical point is associated with decreased breastfeeding initiation (Foster & McLachlan, 2007; Moore & Anderson, 2007). In a randomized controlled trial, skin-to-skin contact between the mother child dyad post birth was associated with an average time from birth to breastfeeding initiation of 40.62 min, significantly shorter than the average time from birth to breastfeeding initiation of 101.88 min in the usual care group where children were wrapped (Mahmood, Jamal, & Khan, 2011). Breastfeeding exclusivity and duration were also shown to improve with skin-to-skin contact. (Bramson et al., 2010; Hake-Brooks & Anderson, 2008).
Cosleeping was found to be positively associated with breastfeeding duration (McKenna, Ball, & Gettler, 2007; Taylor, Donovan, & Leavitt, 2008). Mothers who cosleep with their infants were shown to breastfeed their infants twice as often as those who did not cosleep (McKenna et al., 2007). Closeness of the maternal-child dyad should be protected and nurses play a critical role in preventing unnecessary separation. Nurses can support skin-to-skin contact for both preterm and term infants. Mothers who are separated from their child due to illness, employment, or other situations need help in maintaining lactation while separated from their child and the support of those caring for their infants in their absence.
Maternal Internal Resources
Maternal internal resources such as intent, self-efficacy, and maternal mental health are antecedents to breastfeeding. Although the relationships between maternal internal resources and breastfeeding are complex and not fully understood, research developments provide insights into these issues. Women who plan to breastfeed are more likely to continue breastfeeding for a longer duration (Meedya, Fahy, & Kable, 2010; Thulier & Mercer, 2009; Walburg et al., 2010). Confidence and self-efficacy has been linked with increased breastfeeding duration (Meedya et al., 2010; Thulier & Mercer, 2009). A positive self-concept in mothers improves the likelihood of exclusive breastfeeding (Britton & Britton, 2008). Nurses can work to foster confidence in mothers through encouragement, teaching about breastfeeding, and facilitating opportunities for vicarious learning.
In contrast, both maternal anxiety and depression are negatively associated with breastfeeding duration (Dennis & McQueen, 2009; Zanardo et al., 2009). Depression was negatively associated with self-efficacy related to breastfeeding and depressed mothers, who breastfed, were also more likely to encounter challenges (Dennis & McQueen, 2009). Nurses play a valuable role in identifying postpartum mothers with anxiety and depression and referring for care. In the case of depression or other issues requiring a breastfeeding mother to take medication, nurses can help prevent unnecessary breastfeeding cessation by using resources such as Medications and Mothers Milk (Hale, 2010).
Maternal External Resources
Maternal external resources such as social and health provider support are antecedents to breastfeeding. Culture and cultural support for breastfeeding significantly affect breastfeeding (Flower, Willoughby, Cadigan, Perrin, & Randolph, 2008; Walburg et al., 2010). Social support has been shown to facilitate breastfeeding (Ladomenou, Kafatos, & Galanakis, 2007; Meedya et al., 2010; Morhason-Bello, Adedokun, & Ojengbede, 2009; Thulier & Mercer, 2009). Family support has been shown to impact breastfeeding including breastfeeding duration (Hegney, Fallon & O'Brien, 2008; Ladomenou et al., 2007; Thulier & Mercer, 2009). Support of the father of the infant was shown to improve timely breastfeeding initiation (Dashti, Scott, Edwards, & Al-Sughayer, 2010). Qualitative analysis of the role of grandmothers in the feeding of their grand children in Malawi highlighted the importance of family support (Kerr, Dakishoni, Shumba, Msachi, & Chirwa, 2008).
Peer support has been associated with breastfeeding (Hegney et al., 2008; Renfrew et al., 2010; Thulier & Mercer, 2009). Labor support was found to significantly improve breastfeeding initiation in a randomized controlled trial conducted in Nigeria (Morhason-Bello et al., 2009). Breastfeeding duration was negatively impacted by women attending a parenting group with a greater percentage of mothers who were not breastfeeding (Cameron, Hesketh, Ball, Crawford, & Campbell, 2010).
Intensive breastfeeding support and postpartum follow-up were positively associated with breastfeeding exclusivity and duration in a cohort that intended to breastfeed optimally (de Onis et al., 2006). The findings of four randomized controlled trials indicate that breastfeeding exclusivity could be improved through community initiatives such as home visits, education, and peer support (Hall, 2010). Prenatal education combined with postpartum support was associated with increased breastfeeding exclusivity (Kupratakul, Taneepanichskul, Voramongkol, & Phupong, 2010).
Nurse's understanding of breastfeeding was shown to be enhanced through breastfeeding training (Watkins & Dodgson, 2010). In the landmark Promotion of Breastfeeding Trial, structural hospital support in the form of the Baby Friendly Hospital Initiative (BFHI) improved breastfeeding practices including length of breastfeeding and exclusivity (Kramer et al., 2001). Researchers subsequently found that BFHI was associated with increased breastfeeding initiation and longer duration of breastfeeding (DiGirolamo, Grummer-Strawn, & Fein, 2008; Foster & McLachlan, 2007; Renfrew et al., 2010). Community and hospital initiatives to improve breastfeeding practices should be supported by nurses. Nurses can participate in formal and informal educational opportunities to increase their knowledge of breastfeeding. During interactions with mother child dyads, nurses can welcome breastfeeding, which supports a mother's efforts to breastfeed and presents breastfeeding as normative.