Welcome to the Milk Mama Diaries Carnival (July). For this month, we join the National Nutrition Council – Department of Health in celebrating Nutrition Month with the theme "Isulong ang Breastfeeding – Tama, Sapat at EKsklusibo!" [This is Tagalog – apparently, it translates as "Push Breastfeeding Forward – Correct, Sufficient, and Exclusive." Participants will share their experiences in promoting breastfeeding or their tips on how breastfeeding should be promoted. Please scroll down to the end of this post and check out the other carnival participants.
OK, compulsory intro over. As you can probably deduce, this blog carnival is based in the Philippines. Undeterred by the fact that I don't know remotely enough about the Philippines to advise on how breastfeeding promotion should best be done there, I figured, hey, no problem, I'll jump in with a post about how I think the healthcare system in the UK should promote breastfeeding. Reading more of the ongoing discussion on how dramatically different the situation is in the Philippines has made me question the wisdom of that blithe decision. While I think at least some of what I say is universally applicable, it's easy for me to talk about breastfeeding as just another of life's choices when I have the luxury of living in a well-off country with a clean safe water supply. I believe there are multiple advantages to breastfeeding even when living in such a country; but they don't begin to compare to the frightening consequences of formula feeding in undeveloped countries. I think that treating the two situations as comparable would be a terrible idea.
However. By the time I'd reached that conclusion the post was practically written, and I do think that the basic principles behind the approach I advocate are universally applicable. So I'm going to go ahead and post it and let other carnival members make the choice as to whether or not they wish to include it on their lists. If any think it more appropriate not to, then I will fully understand that. I also ask anyone from the Carnival who does read this post to bear in mind that it was not written with the Philippines or any other developing country in mind, and that some of what it says will therefore not be applicable. One specific and important example is my belief that it's quite reasonable and low-risk for a woman to give the occasional bottle of formula – the research on which I base this opinion is based entirely in developed countries, and should not be taken as applicable to the situation in countries where safe water supplies are not universally available. In those countries, a single bottle of formula or drink of water can indeed be extremely dangerous for a baby.
So. With all that in mind, this is my vision of how I, as a doctor in the UK, would like to see the healthcare system in the UK go about discussing and promoting breastfeeding. (It is, sadly, very far from the way that it does so at present…)
At the first prenatal appointment, I think it would just be mentioned as something to be discussed at further appointments. This is simply because there's so much else to discuss at that point that it just doesn't seem like the best time to get into such a complicated subject. So I'm picturing it more as something that gets introduced and not gone into – "OK, your next appointment will be in a month's time. At that point we'll check you're OK, have a further chat about what sort of things to expect from the coming months, and start talking about how you want to feed the baby and the pros and cons of the different ways. Meanwhile, here's some information for you to look through." The antenatal pack would contain some leaflets on the subject, introducing the kind of information I'll discuss below.
At the next consultation, the midwife (the prenatal care system in the UK is midwife-led for normal pregnancies) would bring up the topic and ask the woman what thoughts she was currently having on how she wanted to feed her baby. Obviously, at this stage there would be some women who had made a definite decision (which might be for full breastfeeding, full formula feeding, or mixed feeding), some who were thinking more generally in terms of "I'll give breastfeeding a shot and see how it goes", and some who had no idea at all.
This would be the starting point for discussion and information-giving that would be gradually developed as indicated over subsequent consultations from then throughout the woman's involvement with the midwifery services – so, throughout her pregnancy, she would be finding out more about the decision and having the chance to continue all options, and, after the birth, the midwives would be ensuring that things were going well and looking at what they could do to provide help and support if not.
After a woman was discharged from midwifery services, the health visitor would take over the same role – keeping an eye on how things were going, providing support, discussing with women who had difficulties what their options were and what the best way forward would be, and troubleshooting by, for example, warning breastfeeding women about what to expect during growth spurts. Doctors would do the same thing at the six-week check and opportunistically at other times that they happened to see the mother or baby.
During these chats, there would be a lot of points to cover:
- The pros and cons of different feeding choices – discussed as clearly and honestly as possible. This would include both evidence-based information of breastfeeding benefits, and practical considerations.
- The practical information needed to implement whatever choice the woman made – whether this be information on how to get breastfeeding to work out well and where to seek help if needed, or on how to mix formula and sterilise bottles safely, or both.
- For women who wanted to try breastfeeding/mixed feeding, a troubleshooting discussion of the problems and booby traps that might arise, and ways of dealing with them.
- For women who wanted to try formula-feeding, a sensitive discussion of the reasons why, and of whether any kind of compromise was possible. If she was put off by a previous bad experience or by seeing a friend's bad experience, did she know that every breastfeeding experience is different and that breastfeeding another child might not come with the same problems as breastfeeding the first one? If she was put off by the thought of all the initial difficulties to be overcome, did she know that those difficulties don't affect every woman and would she consider it worth at least giving breastfeeding a brief try to see whether it worked out? If she wanted to be able to hand her baby over to someone else for a bottle once in a while, did she know that this was still an option for most breastfeeding mothers (either the much-maligned occasional bottle of formula, or pumped milk)? (She might, of course, flat-out not wish to discuss it at all, in which case the midwife would respect her wishes, let her know that the subject was up for discussion any time she wished to introduce it herself, and let it drop thereafter.)
- For women who wanted to breastfeed exclusively, a discussion of whether to introduce bottles of pumped milk, and, if so, when and how to go about it.
All of this would be backed up by written information that would be available in the initial booking pack given to women, with lots of discussion on where to go for further help if needed.
Midwives would aim to keep all information both honest and easy to understand. This means that:
- They would not try to gloss over potential difficulties. Breastfeeding can be very easy and, when it goes well, is far more convenient than giving formula, but it doesn't always go well and, for some women, can be very difficult indeed. While there's no need to approach the subject with an attitude of what my mother calls 'Doom, doom, on the doom drums', it also doesn't do women any favours not to at least warn them of the possibility that breastfeeding may be a miserable experience for them, and, if so, that this is not absolutely guaranteed to improve with time.
- They would be honest about both what the science shows and what it doesn't. There is extremely good evidence that breastfeeding has a number of health advantages over formula feeding; unless there's some reason such as HIV or a non-negotiable medication regime incompatible with breastfeeding why a woman is not even able to give breastfeeding a try, a woman considering formula-feeding should know the information in favour of breastfeeding in order to be able to make a truly informed choice. On the other side of things, breastfeeding promotion campaigns have had a regrettable tendency to leap on any study that shows any apparent benefit of breastfeeding with little regard to the quality of the research, or to flat-out confuse opinion with fact. Where we have strong evidence for a particular benefit of breastfeeding, we should tell women this. Where the evidence is equivocal or there just isn't much of it one way or the other, we should be honest about this too.
- The research would be presented with actual numbers where possible, rather than just a laundry list of diseases for which the risk is reduced by breastfeeding. However, these numbers would not be presented as "Formula feeding increases your baby's risk of this disease by X per cent", but as the actual likelihood of a baby being affected by a particular disease simply as a result of the formula feeding (or, to flip it the other way, the likelihood of a breastfed baby avoiding a particular disease simply as a result of the breastfeeding). The reason for this is that, especially for rare diseases, percentage increases/decreases can be a misleading way to present information. For example, the worrying-sounding figure of a 36% increase in SIDS in formula-fed babies actually equates to, on average, slightly less than a one in seven thousand chance of dying of SIDS as a result of being formula-fed (and, of course, that's before accounting for the fact that you can reduce your baby's risk below average in other ways).
Throughout these discussions, mixed feeding would be on the table (so to speak) as a possible option, rather than the choices being seen as a very black-and-white breast vs. formula. That way, women who felt overwhelmed at the thought of exclusively breastfeeding would be aware that giving breastmilk was still an option, and might feel more able to try to do so. Again, women would of course be given honest and accurate information about the various pros and cons, including the fact that we really don't have a huge amount of data on how mixed feeding stacks up against either full breastfeeding or full formula-feeding, simply because most studies don't consider it as a separate option.
But the most important thing about these discussions would be that the ultimate goal they would be based on would not be that of getting as many women as possible to breastfeed, or to breastfeed for X amount of time, or to breastfeed exclusively. All those goals and targets have fueled the attitude that, at its darkest, has led to health care professionals browbeating women and endangering babies in the name of breastfeeding promotion. Instead, the main guiding principle would be "How can I best ensure that this woman has all the information and support she needs to make a genuinely informed choice with which she is going to feel comfortable?" Because, at the end of the day, that – not breastfeeding – is what matters most.
Check out the other Carnival posts:
Three Ways I Promote Breastfeeding by Example – Dainty @ Dainty Mom
A Simple Breastfeeding Campaign – The Lazy Mama
I Am A Breastfeeding Mom – The Painter's Wife
Why I Don't Nurse in Breastfeeding Rooms – Legally Mom
The Low-Milk-Supply Mommy Did It! – The Odyssey of Dinna
Breastfeeding Promotion Tips from a Formula Feeder (Yes, you read that correctly…) – The Fearless Formula Feeder
On Promoting Breastfeeding – ImPerfectly Created
Milk Mama Diaries 3 – MimmaBenz
Breastfeeding Mama – canDIshhh
I *heart* Breastfeeding – The Mum Side
Spreading the Word on Breastfeeding – Mommy Kuwentos
A Breastfeeding Formula-Fed Mother – Soprano Mother
I am your breastfeeding friend – Lyndel's Mom
Thoughts of a LactatING Counselor: Breastfeeding is More of Psychology! – Handy Mommy
More on Breastfeeding Promotion plus a Guest Post – Chronicles of a Nursing Mom
Celebrating My Magic Milk – Denise
Breastfeeding Sisters – Isis Evasco