The December 1997 American Academy of Pediatrics (AAP) policy statement "Breastfeeding and the Use of Human Milk" heralded a new bias toward breastfeeding in the United States. The policy reflects " . . . the considerable advances that have occurred in recent years in the scientific knowledge of breastfeeding, the mechanisms underlying these benefits and in the practice of breastfeeding." (AAP 1 1) The AAP statement is so bold that its release ignited a flurry of editorial debate. The most contested issue was the statement: "It is recommended that breastfeeding continue for at least 12 months and thereafter for as long as mutually desired (AAP 1 4)." Reporters took this statement to mean exclusive breastfeeding for the first year after birth (Heinig).
Actually, the policy recommends exclusive breastfeeding for the first six months followed by "Gradual introduction of iron-rich solid foods in the second half of the first year which should complement the breastmilk diet (AAP 1 4)." The primary source of nutrition for the first year of life should be breastmilk.
Other features of the AAP policy include:
(AAP 1 3,4)
The statement also incorporates ways in which pediatricians can
enthusiastically promote and protect breastfeeding. (AAP 1 4-5)
A critical, yet overlooked, aspect of the AAP statement is the acknowledgment of the breastfed infant as the "reference or normative model (AAP 1 1)." The breastfed infant is the normal standard against which all research and recommendations for infant feeding should be made. This is a paradigm shift in American scientific thinking. Research in all areas of maternal - child health should use exclusively breastfeeding infants and their mothers as the study controls. Breastfeeding and human milk are the "Gold Standard" by which all infant feeding and developmental issues should be measured.
However, "The term breastfeeding alone is insufficient to describe the numerous types of breastfeeding behavior (Lawrence and Lawrence 15-16)." When reviewing breastfeeding research it is important to note if the type of breastfeeding is defined by the author(s). Some researchers may apply study results to the breastfeeding group if any breastfeeding has occurred at any time. The conclusions drawn therefore, can be incorrect. By identifying the type of feeding as a research variable [Table 1] the occasionally blurred differences between breastfed and artificially fed infants, especially in developed nations, will become abundantly clear.
In promoting "breastfeeding as a normal part of daily life (AAP 1 5)" family, employer and societal support will improve. Media portrayal of artificial feeding as normal should decline. We may even reach a point where advertising artificial feeding to the public, delivery of free product samples and financial incentives to doctors and hospitals from manufactures of artificial baby milk will be regulated by law. Advertisements for artificial baby milk may become as disdainful as those for alcohol and tobacco products because of the serious health consequences they cause.
As we enter the new millennium, we are seeing the third, fourth and fifth generations of mass artificial infant feeding in the perinatal arena. Over half of the women giving birth today were not breastfed themselves, neither were their mothers nor grandmothers. Those who were breastfed did so for a few weeks or months, often with supplementation beginning at birth. Within the typical family unit, there is little support or hands-on experience for the breastfeeding dyad. For the last 80 to 90 years, women have been formula feeding in such great numbers that much of the valuable information we once possessed has been (temporarily) lost. Newman states, "Somehow during the lifetime of our mothers or grandmothers due mostly to profound social changes but also smart marketing bottle feeding became 'normal' in the collective consciousness of western society . . . We must all work now to reestablish the breastfeeding baby as the model for normal society (2-4)."
In the last 50 years, as a response to scientific advances, all
areas of medical and nursing education have undergone extensive
changes except in the area of lactation support and management.
The lack of training leaves health care providers to glean what
they can from their patients and their culture. Unfortunately
the gap between cultural knowledge and the truth is a great crevasse
that can only be bridged by education.
New mothers will turn to you, the health care professional, for
information and assistance when problems occur. A recurring theme
in the research is that advice from health care providers is often
inaccurate and inconsistent. The vast amount of new research in
all areas of lactation, makes it difficult for the medical community
itself to provide current breastfeeding information.
You, as a health care professional, have an increasing level of
responsibility in promoting, protecting and preserving breastfeeding,
despite your chosen subspecialty.
Do women and medical professionals need classes to learn how to
breastfeed? Absolutely.
The Role of the Medical Professional in Breastfeeding Support
Since the Surgeon General's Workshop on breastfeeding in 1984 all maternity settings are mandated to provide a supportive milieu for breastfeeding. All health care professionals are therefore required to support breastfeeding. At the nucleus of this mandated support is a strategy where breastfeeding education begins in the antepartum setting and continues though the pediatric care of the infant. Hospitals are to have a specially trained person available to help the breastfeeding dyad. By improving the perinatal setting, it was hoped that by the year 2000 at least 75% of all women will be nursing their newborns at hospital discharge and 35% would continue to breastfeed for a minimum of six months (Surgeon General's Report: 3 and Spisak and Gross). The key elements of the Surgeon General's [Table 2] workshop were incorporated into the Healthy People 2000 project and restated in the Goals of Healthy People 2010.
With new information and support systems, breastfeeding initiation rates have been on a pitifully slow incline in the United States. Historically, infant feeding surveys reflect infants who have been to the breast at any time and those who are merely token breastfed. In 1890 nearly 100% of all infants were breastfed. The high point for breastfeeding initiation in the U.S. was in 1982 with 62% of newborns breastfeeding at the time of delivery and 30% nursing at six months. By 1985, the numbers dropped to 58% at birth and 22% at six months. 1989 saw an additional decline to 52% at time of delivery and 19% at six months. By 1995, the number of U.S. women who initiated any breastfeeding in the hospital increased to 59% across all socioeconomic groups. Less than 12% are nursed beyond 6 months. The greatest gains in initiation rates were seen among African Americans 31%; Hispanics 56%; and Native Americans 51%; narrowing the gap with the total U.S. population (Healthy People 2000: Mid-course Review 95). According to Healthy People 2000, there has been little progress in the numbers of infants who are breastfeeding at 5 to 6 months postpartum.
A few individual hospitals scattered throughout the U.S. have
better than average initiation rates, some as high as 95%. Unfortunately,
the numbers drop off quickly in the first weeks postpartum. To
date, no records have been kept on the duration of exclusive breastfeeding.
However, the number of infants exclusively breastfed during the
first six months of life is down worldwide.
The United States has one of the poorest mortality and morbidity
rates of developed countries. In the United States, "nearly 35,000
babies died before their first birthday in 1992, a rate of 8.5
per 1,000. For every 1,000 babies born to black mothers that year,
16.8 died before their first birthday (Knight Rider News Service
2/8/96)." By 1994 the neonatal death rate declined slightly to
7.9 per 1000 live births, but African American infants died "at
a rate of more than twice that of white infants (Healthy People
2000: Progress Review 7/2/96)." Besides the AAP, all major medical
societies in the United States recommend breastfeeding for as
long as possible in infancy. To improve childhood survival rates,
the World Health Organization and United Nations Children's Fund
(UNICEF) guidelines recommend extending breastfeeding for a minimum
of two years. World wide nearly "1.5 million infant deaths in
the world each year could be prevented by improving the practice
of breastfeeding (WHO 1995)." Exclusive breastfeeding or human
milk feeding for a minimum of six months provides the greatest
level of protection against infantile illnesses (see: Hazards
Associated with Artificial Baby Milks.)
Despite the growing evidence that breastfeeding is best feeding,
attitudes of health care professionals continue to be verbally
and non verbally unsupportive. Slusser and Powers state "A number
of studies have found that health care providers represent one
of the major barriers to successful breastfeeding (111)." Mothers
have said that "if their physician would tell them breastfeeding
is important, they would do it for as long as the physician said
(Lawrence and Lawrence 15)." Unfortunately, physician's and nurse's
knowledge about breastfeeding is severely lacking (Lawrence and
Lawrence 208; Sable and Patton 35). Medical and nursing school
curricula include little more than a lecture about breastfeeding.
Powers, Naylor and Wester state that clinical lactation skills
should be taught "by an experienced clinician to perinatal providers
in the clinical setting and subsequently to new mothers (518-519)."
The individual health care provider may not know how to help women
breastfeed. Rarely, is hands-on experience a part of the educational
process for the health care professional (Freed et al). Very few
health care providers have had the opportunity to observe a lactation
consultant at work in clinical practice.
Language, Actions and Breastfeeding
Professionals often present a two sided attitude. The language
we use to educate women about breastfeeding is riddled with semantics
that place artificial feeding and breastfeeding on the same plane,
with only a slight difference in the method of delivery. The author
believes that "breastfeeding is the norm and that artificial feeding
is a deviation from the norm that brings about hazards to infant
health (Riordan and Auerbach 135)." The author has chosen to change
her use of language within this text to reflect the breastfeeding
norm. Language deeply influences our thoughts and actions. Fallacies
and myths about breastfeeding, quite simply, are born of, and
perpetuated by, poor word usage (Auerbach 1998). As long as we
continue to present the hazards of artificial feeding, candy coated
with euphemisms, health care providers and the general public
will continue to believe that artificial baby milk is just as
good as mother's milk. [TABLE 3] "We cannot expect to create a
breastfeeding culture if we do not insist on a breastfeeding model
of health both in our language and our literature (Wiessinger
1)."
Health care professionals must also think carefully about their
actions. Our actions have a greater effect than our words. Our
innocent deeds resonate within the unconscious mind of the mother.
Occasionally we may find ourselves advertising for artificial
baby milk (ABM) manufacturers. Company representatives drop off
pens, cups, posters and "educational materials" emblazoned with
the name of a formula or the manufacturer's company logo
Few professionals recognize the negative impact on breastfeeding
success through their "(unintentional) endorsement of infant formula
products by displaying breastfeeding materials (free gifts, formula
coupons, booklets) produced by formula manufacturers. The conflict
of interest presented when formula companies 'advise' woman about
breastfeeding should be obvious . . . (Powers, Naylor and Wester
517)." Giving new mothers a sample of ABM at hospital discharge
is a powerful tool to undermine her breastfeeding confidence.
In essence that sample says, "Keep this nearby; just in case you
don't have enough milk." Discharge packs, diaper bags with ABM
samples, videos, discount coupons etc., may seem like nice "gifts"
for the mother but they have been repeatedly shown to decrease
the length of exclusive breastfeeding (Frank 7-10), and are in
direct violation of section 5.2 of the WHO International Code
of Marketing of Breastmilk Substitutes. When I ask mothers why
they use a particular brand of formula they tell me, "It's the
one the hospital gave me." ABM companies are well aware that when
a hospital or doctor's office gives new mothers a sample, it is
a tacit recommendation of their product. Even non-formula related
gift packs have anti breastfeeding implications. They often contain
coupons for bottles and bottle feeding paraphernalia.
When a slight breastfeeding difficulty arises, if you are not
educated in ways to support lactation, the easiest solution is
often a bottle. Unwittingly, health care professionals are sending
mixed messages when they insist on supplementation for normal,
healthy, neonates who are breastfeeding. Supplemental bottles
loudly say to the mother, "your milk isn't enough."
Creating Acceptance
The Baby Friendly Hospital Initiative (BFHI)
In 1991, WHO and UNICEF launched a campaign to create change in
health care facilities; The Baby Friendly Hospital Initiative.
Its aim is to foster an environment that "supports, protects and
promotes breastfeeding" as dictated by the WHO International Code
of Marketing Breastmilk Substitutes. (Baby Friendly status does
not mean that other hospitals are baby unfriendly.) "The process
for obtaining certification as a Baby Friendly Hospital has been
established by UNICEF in collaboration with the national governments
in more than 175 countries (Gartner 2)." UNICEF's Ten Steps to
Successful Breastfeeding are the basis for evaluating hospitals
and health care facilities for participation as a designated Baby
- Friendly facility.
Many breastfeeding guidelines that were previously rejected are
being seen in a new light. Table 4 is an edited version of the
evaluation tool for the Baby-Friendly designation.
Many hospitals have already made the changes necessary for Baby
Friendly Hospital status and have received Certificates of Intent.
Pessi and Auerbach pointed out areas of difficulty with each of
the ten steps based on common practices here in the United States
(189-192). The Baby Friendly Hospital Initiative, and the WHO
code for Marketing Breastmilk Substitutes can and should be carried
out in the US, but it will take much more time than initially
anticipated. If the BFHI is to be nationwide, many changes will
need to be made at all levels of health care: beginning with education
of health care professionals, hospital administrators, and third
party insurance providers. Breastfeeding knowledge must be disseminated
to the public. Difficulty can be expected in attempting to establish
supportive change within the health care system, if we are to
reach the newly proposed target date of the year 2010.
Agents for Change
"It is time for enthusiastic encouragement [to breastfeed] backed
by meaningful action and time to move forward from personal perceptions
and experiences to demonstrate to the culture at large that breastfeeding
is normal, acceptable and achievable (Slusser and Powers 118)
While most nurses feel that their hospital routines provide the
best care for those in their charge, the Baby-Friendly evaluation
clearly shows the scope of hospital practices that have detrimental
effects on successful breastfeeding.
But, getting hospital policies changed is difficult. Some routines are so deeply ingrained that the staff members are often unable to identify and correct problems. Resistance to change comes naturally to most people. "Common mistakes in attempting to implement change include ambiguous objectives, poorly defined strategies and the use of a limited number of change agents and techniques (Riordan and Auerbach 245)."
Education about a need for change normally precedes any desire for change. A structured approach that incorporates training, motivation and specific practices for implementation is needed (Riordan and Auerbach 80). Starting a breastfeeding task force can be an important first step in change. A task force can look at barriers to breastfeeding within the hospital and spearhead application for Baby Friendly status. Members on the task force should include staff nurses, clinicians, educators, and representatives from the medical disciplines including Obstetrics, Pediatrics and Family Practice. In some hospitals, change may occur more rapidly if an outside agent is brought in to evaluate the situation and make recommendations to the task force. Setting a target date for the task force to conclude their research and begin implementation is important.
Breastfeeding Issues Inspire Emotions in Medical Providers
"Nowhere in medicine do one's personal interests or prejudices become more evident than in the area of counseling about childbirth and breastfeeding (Lawrence and Lawrence 233)." Because of deep emotional connections, breastfeeding is an emotionally charged issue for health care providers. "Physicians and nurses are notoriously eager to provide advice, even if their knowledge of, or experience with, the subject is limited (Stuart-Macadam and Dettwyler, ix)." Most nurses have both positive and negative experiences with breastfeeding women or as mothers themselves. We bring to the bedside our own set of cultural values and emotions that affect our patients' breastfeeding experience. Lawrence and Lawrence state that physicians' attitudes about breastfeeding are influenced by how their own children were fed. They also cite a study that showed that female physicians were more apt to discredit breastfeeding help offered by lay groups. (208)
Health care providers should try not to let their personal feelings interfere in the way they approach the nursing couple.
Copyright Marie Davis, RN, IBCLC 1999
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