As a society our attitudes toward breastfeeding remain quite split. Those of us who want to encourage women to breastfeed often underestimate the barriers faced by some women considering breastfeeding. There may be subconscious negative perceptions of what breastfeeding is, and a lack of support from family members who share these perceptions. The many advantages of breastfeeding have been detailed in this newsletter before, and I think most women accept that breastfeeding is "better", as do their physicians. However, if we really want to see more women breastfeeding for their and their children's well being, we need to provide both the most accurate knowledge to deal with medical or mechanical difficulties (the how-to's) as well as the knowledge to overcome negative feelings and attitudes about breastfeeding.
I have repeatedly found that it is no use concentrating on the advantages of breastfeeding to a woman's baby if she feels discomfort or physical unease at the very thought of breastfeeding and cannot overcome those feelings. As a physician providing prenatal care and attending births, I am repeatedly struck by the power of the attitude a woman brings with her at her first prenatal visit. For some, it's an automatic assumption that breastfeeding is a positive and enriching extension of the pregnancy experience. For other women, it is a decision fraught with mixed feelings and lack of confidence. "Do I want to be doing this?" appears as a dominant question.
If healthcare providers are to make a difference to women who wish to breastfeed, we need to educate ourselves to be a resource to you. We also need to understand and work to address the barriers women face that prevent them from breastfeeding. I mention the former because repeated studies show that doctors of all kinds (pediatricians, family physicians and obstetricians) are not, on average, adequately trained in breastfeeding information. In a study published in the Journal of the American Medical Association, (Feb. 2. 1995), it was shown that amongst all these types of doctors, more than 90 percent endorsed breastfeeding, but less than 50 percent knew what correct advice to give regarding some medical problems related to breastfeeding, and more than 30 percent chose incorrect advice for women with low milk supply. This means that while the average physician is supportive of your breastfeeding, you should never give up on a breastfeeding problem until you have talked to people with practical working knowledge of breastfeeding, be they lactation consultants who have formal training, or a breastfeeding experienced mother with some good books to turn to.
SOCIAL BARRIERS
Social barriers to breastfeeding are many, and are the first ones which need to be overcome. There is an urgent need for society to work to support breastfeeding mothers first, before many individual women will feel able to overcome their sense of breastfeeding as a strange, socially disapproved activity.
EMBARRASSMENT
My perception is that this is far more of a barrier than is commonly realized or written about. When I talk to women about their decision to stop breastfeeding early (first week to 2 months), the reasons given are often connected to going back to work, inadequate milk supply, or inconvenience. On further exploration, so often women acknowledge that their body image makes them uncomfortable at the idea of breastfeeding, or that at the point they were ready to be out and about they were intimidated by the thought of how to breastfeed discreetly in public. This leads to early introduction of formula in a bottle, then to a decrease in milk supply and a discontinuation of breastfeeding. Because this is a nonmedical, and indeed very delicate social issue, it is rarely addressed directly. Women do not often think to seek advice in this matter, and don't often consciously consider the tremendous impact these perceptions of discomfort around breastfeeding in public or even at home affect their decision. We have a drought of media images and actual experience of seeing women breastfeed. By providing these images, we would pave the way for greater ease of mind and breastfeeding success amongst new mothers. Practically speaking, a lot of everyday clothing such as loose shirts or blouses with a nursing bra may be used for positioning babies with a minimum of skin exposure or fuss. Practising at home for some time can increase comfort. Getting your baby used to feeding with his head covered under your clothing early on, is a good idea for anyone planning ahead for smooth public feeding. A number of specialized manufacturers now provide nursing clothing to simplify breastfeeding discreetly. Discussing these issues directly during pregnancy may help with planning for these later needs.
FEAR OF DISCOMFORT
Women often say to me, "I've heard breastfeeding is painful”. If this information has a source outside of rumor, it seems often to come from friends who had initial difficulties breastfeeding, and stopped. Engorgement, with sore breasts full of milk, may add to this perception when they stop. In general, some nipple sensitivity or soreness in the first few weeks is probably to be expected. However, breastfeeding should never normally be painful or cause bleeding. These are problems that help should be sought for, most likely to do with incorrect positioning of the baby on the breast. Cracked nipples may have a yeast infection that can be treated, nipple shields should be avoided, and pumping milk is best avoided for the first few weeks if possible. Air drying nipples and avoiding the use of creams is also helpful. Many women have not heard that breastfeeding can be a very pleasurable sensation. In addition, it leads to the release of hormones, which seem to help create feelings many women describe as "mellowing”. These feelings of calmness, relaxedness or mellowing, seem to be ideal for creating a special space around the new mother and baby. They seem to be a needed remedy for the stresses of learning to be with a new infant.
LACK OF SUPPORT
A woman's decision to breastfeed is very much influenced by the supportiveness of her partner, and often the attitudes of her mother or other parenting experienced women around her. This is why education about breastfeeding advantages, and social changes that allow all of us to see breastfeeding as a normal and unremarkable activity in public or private are so important. I have often seen that even a woman motivated to breastfeed has stopped when faced with her own mother's lack of support for her practice. Many of today's grandmothers had children in an era when it was largely thought that artificial formula was better than breast milk.
MEDICAL BARRIERS
Medical problems that might complicate breastfeeding are many, and I will not detail them in this article. However, the single most important principle to deal with most problems, is that milk supply is determined by nipple stimulation. Therefore, if milk supply doesn't seem enough, increasing the frequency of feeds will allow for an increase. The common mistake of adding formula results in decreased feeds at the breast and therefore the opposite effect of cutting down milk supply. Similarly, the action of the baby's sucking is far better for milk production than pumping. So if pumping is begun before milk production is well established, then it would need to be at very frequent intervals (at least every 2 to 3 hours) to allow for enough stimulation to produce milk. If a woman has set a goal of breastfeeding for a certain length of time, then problems such as jaundice in her baby, or her own mastitis (an infection of the breast tissue) should not be reason to stop breastfeeding. With the right information and support, there is rarely a medical reason to stop breastfeeding, short of definite failure of the baby to get enough nutrition, and to gain weight. This problem is actually quite rare, and more often seen in premature infants or those who are unable to coordinate a good sucking reflex.
GROWTH SPURTS
A problem that often comes up is one of a frustrated baby who suddenly acts hungry all the time and not satisfied with the amount of milk she's getting. This most often happens around 2 weeks, 4 weeks, 6 weeks or 3 months. I commonly hear disappointed women tell me later that they suddenly didn't have enough milk and for fear of starving their baby, started adding formula. While some women are able to supplement in this way, many notice their own supply dry up quickly. These are normal baby growth spurts, and are best dealt with by taking the time for extra frequent feeds while mother and baby are awake, even every hour, for a day or so. That's usually all it takes to bump up the milk supply to meet the new demand. Knowing this might happen ahead of time is a big reassurance, and helps keep the whole family from worrying.
WORKING & PUMPING
A word on working and breastfeeding. Certainly, the need to return to work at 6 weeks is one of the biggest challenges to breastfeeding in working women. The longest period that you can exclusively breastfeed the better. So if you were to make the decision not to use a breast pump at work, you would still benefit from exclusively breastfeeding until the time of starting work. While it's always a tough transition for mother and baby, the baby will certainly get used to the bottle at that time, without adding a bottle from birth. It does take extra motivation to learn not only how to breastfeed, but also the mechanics of pumping and storing milk. We live in a society where tremendous constraints are placed on working families, without support systems to make such things as pumping in the workplace straightforward: If you are wanting to exclusively breastfeed after going back to work, enlisting your doctor or midwife's support is a good idea. A note to your employer may be helpful in advocating for finding you a private space to pump in a few times a day. Working out the details ahead of time helps make the return to work less stressful. Another technique to help the working woman is referred to as 'reverse cycle feeding'. This involves allowing your baby more frequent feeds at night so that you need to pump less during the day. For this to work while allowing for an adequate night's sleep, your baby sleeps with you, and you schedule about an hour more of sleeping time than your usual. The advantages include more bonding time with your baby than a working woman otherwise might have, and the need to pump much less while at work. This is not a workable solution for a couple who do not wish to bring their baby into bed with them. When all is said and done, breastfeeding successfully requires the motivation to do so. Exposure to positive images associated with breastfeeding, and the professional support to get over difficulties if they do arise, are important factors. I wish that every new mother could have the knowledge and support to breastfeed for as long as she would ideally choose to, be that 6 months or 2 years.