Preparing for breastfeeding

Assisting women to plan for breastfeeding by providing information and support may increase initiation and duration of breastfeeding, with health benefits for mother and infant.

10.1 Background

In Australia, the Australian National Breastfeeding Strategy 2010–2015 AHMC 2009 (a revised strategy is under development) and the Infant Feeding Guidelines NHMRC 2012 provide guidance on supporting breastfeeding at primary care, hospital and government levels.

10.1.1 Health benefits of breastfeeding

A large body of Australian and international evidence shows that breastfeeding is of significant benefit to babies and mothers AHMC 2009.

• Babies: Breastfeeding has a range of benefits for the developing baby, including improved visual acuity, psychomotor development (Horta et al 2007) and cognitive development (Kramer et al 2008). Breastfed babies have a reduced risk of a range of serious illnesses and conditions such as gastroenteritis, respiratory illness, otitis media, allergy and sudden unexpected death in infancy (SUDI) (Ip et al 2007). They are also less likely to develop chronic disease later in life Horta et al 2007, Ip et al 2007
• Mothers: Breastfeeding promotes faster maternal recovery from childbirth and return to pre-pregnancy weight and delays return of menstrual periods. Women who have breastfed have reduced risk of breast and ovarian cancer in later life NHMRC 2011
• Mother-infant attachment: Breastfeeding may assist bonding and attachment between mothers and babies NHMRC 2011.

Exclusive breastfeeding (no solids or liquids besides human milk, other than vitamins and medications) for 6 months has several advantages over exclusive breastfeeding for 3 to 4 months, including reduced risk of gastrointestinal and respiratory infection (Kramer & Kakuma 2007). No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings (Kramer & Kakuma 2007).

10.1.2 Initiation and duration of breastfeeding in Australia

The Australian Infant Feeding Guidelines recommend exclusive breastfeeding for 6 months and continuing breastfeeding for one year or for as long as mother and child desire NHMRC 2012. The 2010 Australian National Infant Feeding Survey found that breastfeeding was initiated for around 96% of infants and that around 90% of infants received breast milk as their first feed AIHW 2011. Figure B1 shows rates of exclusive and any breastfeeding over the first year of life from the survey.

There are regional and jurisdictional variations in rates of breastfeeding AHMC 2009. Rates of breastfeeding are also influenced by other demographic factors AIHW 2011.

• Aboriginal and Torres Strait Islander mothers: The 2010 National Infant Feeding Survey found that 59% of Aboriginal and Torres Strait Islander infants were exclusively breastfed at less than 1 month, 33% at less than 3 months and 7% at less than 6 months (DoH 2012). Rates of ‘any breastfeeding’ were higher in advantaged areas than disadvantaged areas (99% vs 93%) DoHA 2012. Recent studies in Aboriginal health services in Darwin (Josif et al 2012) and Brisbane (Stapleton et al 2011) have found rates of exclusive breastfeeding on discharge from hospital of 88% and 69%, respectively. A survey conducted in Western Australia in 2000–2002 found that breastfeeding duration increased with remoteness (Cromie et al 2012).
• Country of origin: Evidence is mixed as to whether breastfeeding rates among migrant and refugee women are comparable to the general Australian population rates, with studies finding no difference in rates of exclusive breastfeeding on discharge from hospital (Dahlen & Homer 2009) but lower rates of breastfeeding at 3 months among migrant and refugee women (Stephens 2001). It has been reported that breastfeeding practices vary between different cultural groups in Australia, reflecting trends in their countries of origin AHMC 2009.
• Age: In 2010, breastfeeding at 6 months was reported by 64.1% of women aged more than 35 years, 63.5% of women aged 30–35 years, 56.7% of women aged 25–29 years and 39.1% of women aged 24 years or younger AIHW 2011.
• Socioeconomic status: In 2010, breastfeeding at 6 months was reported by 68.7% of women in the least disadvantaged quintile and 52.4% in the most disadvantaged quintile AIHW 2011.
• Education: In 2010, breastfeeding at 6 months was reported by 73.1% of women with a Bachelor degree or higher, 52.0% of women with Year 12 or equivalent and 40.3% of women who did not complete Year 12 AIHW 2011.

10.1.3 Factors affecting establishment of breastfeeding

The Infant Feeding Guidelines identify a range of factors that affect establishment of breastfeeding NHMRC 2012:

• caesarean section
• separation of mother and baby (eg not ‘rooming in’)
• early use of bottles or pacifiers (dummies)
• offering supplementary feeds (water, glucose or formula milk) when there is no medical reason.

The Baby Friendly Hospital Initiative, which aims to support successful initiation and maintenance of breastfeeding, recommends that women be assisted to initiate breastfeeding within 1 hour of birth and given advice on maintaining lactation.

10.1.4 Factors affecting decision-making about breastfeeding

Environmental factors and societal considerations have an impact on a mother’s commitment to and ability to continue breastfeeding AHMC 2009. Factors that negatively influence initiation and continuation of breastfeeding include (Qld Health 2003):

• physical: maternal obesity, maternal diabetes, low birth weight or prematurity, multiple birth, congenital anomalies, cracked nipples, separation of mother and baby after birth leading to a delay in onset of milk (eg following caesarean section)
• psychological: lack of confidence in breastfeeding, personal image, depression and anxiety
• social: maternal attitude (eg lack of intention to breastfeed), knowledge and attitude of partner and family, community customs and traditions, cultural attitudes to breastfeeding, isolation from family or community, relationship problems, public perceptions, return to work
• environmental: overcrowding in the home environment, lack of facilities to breastfeed in public areas, employment and work environments that do not support breastfeeding.

Some women (eg adolescent women, young Aboriginal and Torres Strait islander women) experience a cluster of these factors, which can influence their decisions about continuing breastfeeding.

A planned approach and continuity of care and support during pregnancy, birth and early parenthood can ensure that women receive opportunities for education, consistent advice, and appropriate support to continue breastfeeding that considers their individual situation.

Maternal conditions and breastfeeding 

The Infant Feeding Guidelines NHMRC 2012 advise that:

• women with HIV should avoid breastfeeding if replacement feeding is acceptable, feasible, affordable, sustainable and safe
• women with hepatitis B or hepatitis C can breastfeed without risk of transmission to the baby.

Tobacco, alcohol and illicit drugs 

The Infant Feeding Guidelines NHMRC 2012 advise that:

• breastfeeding remains the best choice, even if the mother continues to smoke
• not drinking alcohol is the safest option for women who are breastfeeding
• illicit drugs should be avoided while breastfeeding (specialist advice is needed for each individual).

10.2 Antenatal breastfeeding promotion

The objectives of antenatal breastfeeding promotion are to AHMC 2009:

• provide opportunities for pregnant women and their families to learn about the benefits of breastfeeding
• encourage and enable pregnant women to make informed decisions about breastfeeding
• encourage families and support networks to appreciate the benefits of breastfeeding.

Health professionals have a responsibility to promote breastfeeding first but to educate parents individually about formula feeding where it is needed. This responsibility is outlined in the WHO International Code of Marketing of Breast-milk Substitutes and the Australian Infant Feeding Guidelines NHMRC 2012.

10.2.1 Effect on initiation and duration of breastfeeding

Systematic reviews have shown that antenatal breastfeeding promotion can be effective in increasing initiation rates and duration of breastfeeding, especially among groups of women with low breastfeeding rates Dyson et al 2005, Renfrew et al 2005, Chung et al 2008, Lumbiganon et al 2011. Evidence from small RCTs Bonuck et al 2005, Kupratakul et al 2010, Rasmussen et al 2011 and lower level studies Reeve et al 2004, Gill et al 2007, Lin et al 2008, Spiby et al 2009, Ingram et al 2010 is inconsistent.

A combination of antenatal and postnatal interventions increases the initiation and duration of breastfeeding (Chung et al 2008).

10.2.2 Models of care

Studies evaluating breastfeeding promotion interventions have found that:

• initiation rates were significantly improved by antenatal interventions, including health professional support (Dyson et al 2005), peer support/counselling Dyson et al 2005, Chung et al 2008, Lumbiganon et al 2011 and education sessions for fathers (Wolfberg et al 2004)
• duration of exclusive breastfeeding was improved by antenatal group education about breastfeeding (Lumbiganon et al 2011), health professional support provided antenatally (Lumbiganon et al 2011) and home visits both antenatally and postnatally (Anderson et al 2005)
• duration of ‘any breastfeeding’ was improved by antenatal group education about breastfeeding (Rosen et al 2008), health professional support provided antenatally Lumbiganon et al 2011, Pannu et al 2011, peer support (Kaunonen et al 2012) and home visits provided both antenatally and postnatally (Kemp et al 2011)
• combined antenatal and postnatal group education about breastfeeding and peer counselling for adolescent women positively influenced duration of breastfeeding (Wambach et al 2011).

Although peer support interventions increase breastfeeding continuation in low- or middle-income countries, especially exclusive breastfeeding, the effect does not seem to be as strong in high income countries (Jolly et al 2012).

Educational materials provided antenatally were effective when combined with counselling but not as a stand-alone intervention (Mattar et al 2007).

A combination of methods of education and support is more effective than a single method (Hannula et al 2008). A collaborative approach to breastfeeding promotion that involves local health professionals may be more effective than a breastfeeding expert approach (Hoddinott et al 2007).

There is no evidence to support antenatal breast examinations as a means of promoting breastfeeding (Lee & Thomas 2008).

10.3 Discussing breastfeeding

Discussing breastfeeding is an important part of antenatal care. As the preparatory stage for breastfeeding, the goal is to enable women to develop knowledge and commitment and establish or consolidate support networks AHMC 2009. A commitment to breastfeeding includes viewing it as the biological and social norm for infant and young child feeding. The extent to which a mother commits to breastfeeding can influence the duration of breastfeeding (Shealy et al 2005).

Discussion of breastfeeding should involve partners and cover:

• the health benefits of breastfeeding for the infant (eg lower risk of infection) and the mother (eg improved recovery from childbirth and return to pre-pregnancy weight, reduced risk of pre-menopausal breast cancer)
• a woman’s previous experiences of breastfeeding and any concerns related to these
• how partners can support the mother to breastfeed and be involved in other aspects of baby care (eg bathing, nappy changing)
• the importance of uninterrupted skin-to-skin contact at birth and early breastfeeding, including the benefits of colostrum for the infant
• that it is recommended that babies be exclusively breastfed for 6 months and that breastfeeding continue for one year or for as long as mother and child desire
• the importance of good positioning and attachment, rooming in and feeding on demand
• indications that the baby is ready for a feed and is receiving enough milk
• the need to avoid bottles, teats and dummies while breastfeeding is being established
• that water is not necessary for the baby: breast milk is sufficient food and drink for the first 6 months
• the importance of healthy eating (see Section 11) and iodine supplementation (see Section 11.2.2) when breastfeeding
• when to seek advice (eg while some discomfort is not unusual at initiation, advice on attachment should be sought if pain continues)
• the availability of breastfeeding support locally (eg peer support, lactation consultant).

Women may choose not to breastfeed for a range of reasons (eg anxiety, medication use) and the discussion should be approached with sensitivity to these issues. A mother’s informed decision not to breastfeed should be respected and support and information from a health worker and/or other members of the multidisciplinary team provided NHMRC 2012.

Some centres encourage women to express and store colostrum before the birth so that it can be provided to the baby if needed (eg if the mother has insulin treatment for diabetes). While the benefits of early colostrum are well documented NHMRC 2012, the benefits of antenatal breast expression are yet to be substantiated (Chapman et al 2012). However, it does not appear to be harmful among women with diabetes in pregnancy who are at low risk of complications (Forster et al 2017).

10.4 Practice summary: breastfeeding

When

At all antenatal visits.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander Health Practitioner
• Aboriginal and Torres Strait Islander Health Worker
• multicultural health worker
• lactation consultant
• peer breastfeeding counsellor
• childbirth educator
• accredited dietician.

What

• Discuss why breastfeeding from birth is important
  It is important to provide consistent information on the health benefits to baby and mother. Explain that exclusive breastfeeding is biologically and nutritionally appropriate to support growth for 6 months and means that the baby receives only breast milk (ie no other liquids or solids except vitamins or medications if indicated).
• Provide practical advice
  Give information about local support for timely assistance with breastfeeding difficulties (eg postnatal home visits, lactation consultants, Australian Breastfeeding Association, peer support).
• Involve partner or family
  Discuss the importance of support for the mother to enable breastfeeding.
• Provide information
  Give booklets/ handouts relating to breastfeeding that are appropriate for the woman. Information should be available in a language that is understood. All information should be free of marketing for formula, bottles and teats.
• Take a holistic approach
  In discussing breastfeeding, do not assume that a woman knows how to breastfeed. Reinforce positive attitudes to breastfeeding and tailor advice and support to a woman’s individual circumstances, including cultural background. Be aware of different beliefs and cultural practices and explore these with women during pregnancy. Discuss solutions for potential difficulties (eg need to return to work).
• Document discussions
  Note a woman’s intentions about breastfeeding in her antenatal record. The use of a checklist may provide a prompt for health professionals to ensure discussion regarding feeding intentions has taken place.

10.5 Resources

• AHMC (2009) The Australian National Breastfeeding Strategy 2010–2015. Canberra: Australian Government Department of Health.
• Australian Breastfeeding Association.
• NHMRC (2012) Appendix G: Australian nutrition and breastfeeding resources and websites. In: Infant Feeding Guidelines for Health Workers. Canberra: National Health and Medical Research Council.
• NHMRC (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.
• Remote Primary Health Care Manuals. (2017). Breastfeeding. In Women’s Business Manual (6th edition). Alice Springs, NT: Centre for Remote Health.
• Wiessinger D, West D, Pitman T (2010) The Womanly Art of Breastfeeding. 8th Edition. New York: Ballantine Books.