Down with rules!

Brisbane, Australia – It’s time to do away with breastfeeding rules.

This week, I am in Australia as a traveling speaker for the Australian Breastfeeding Association, sharing perspectives with an international team of speakers and with hundreds of dedicated breastfeeding counselors, lactation consultants, midwives and physicians.

Compared with the US, Australia seems like a breastfeeding paradise: every mother gets multiple home visits after birth from an experienced maternal-child health nurse. Each mother also enrolls in a local, health-professional led mother’s group. Baby Friendly hospitals are becoming the dominant paradigm, and 90% of mothers initiate breastfeeding. And yet, breastfeeding rates fall off in the first month, and rates of exclusive breastfeeding are hardly higher than here in the US.

The opening speaker for our traveling seminar is Lesley Barclay, a midwife and researcher who has spent her career improving systems of care for mothers and infants. She argues, in a talk grounded in careful qualitative research, that professionalization of breastfeeding and rigid implementation of rules has undermined breastfeeding mothers.

Barclay traces the history of breastfeeding support in Australia, and she notes a shift from mother-to-mother peer support to professional, expert-to-novice models that can weaken a woman’s confidence and prioritize breast milk delivery to babies over the mother-baby relationship.

For example, she notes that the Baby Friendly Hospital Initiative can have a perverse impact on breastfeeding. She and her colleagues have found that rigid implementation of rules about pacifiers and rooming-in can pit hospital staff against a mother’s heartfelt request to get a few hours’ sleep. Mothers, Barclay argues, should make decisions about their babies, rather than be at the mercy of hospital policies.

Barclay notes that a hospital postnatal ward can be a terrible place for a healthy mother-baby dyad to begin their breastfeeding relationship. Policies that count diapers, time feedings and probe for problems end up treating mother and baby as a machine vulnerable to malfunction, creating iatrogenic illness.

Instead, Barclay advocates for authentic presence, in which a caregiver stands by to encourage and support the new mother as she learns to nurture her baby. She suggests that early discharge, with home follow-up visits from a skilled midwife or mother-baby nurse, could provide a far more natural, relaxed environment for learning to breastfeed.

Barclay also critiques presciptive, rigid advice from health professionals. When we turn breastfeeding into a medical event, fraught with instructions and prohibitions, we assert our expert authority and prohibit a mother from using her own instinct and judgement to nurture her baby.

“We have built the perception that breastfeeding is technically challenging and too hard to do without professional help,” she says. “What happens to a woman’s self-confidence and capacity for decision-making when faced with a barage of professional help and institutional structures?”

I remember, when my first child was born, that I desperately wanted a manual with step-by-step instructions for flawless mothering. I was terrorized by a book that prescribed E-A-S-Y (Eat, Activity, Sleep, You) as the founding principle of successful parenting, and I dispaired when my baby showed no interest in this one-size-fits-all prescription.

Ten years later, here in Australia, Barclay suggests that mothers remain at the mercy of rigid, rules-based advice that undermines their confidence and presages breastfeeding failure.

Mothering — and breastfeeding — is not a technical procedure. It is a relationship between two people that grows with mutual trust and intimacy. We can no more give a mother and baby a step-by-step manual to create that nurturing relationship than we can provide a foolproof instruction book to achieve an orgasm.

“We need to regain confidence in the ability of our bodies to work beautifully in tune with our babies,” Barclay says.

We need to do away with the rules.

Alison Stuebe, MD, MSc is a maternal-fetal medicine physician at the University of North Carolina at Chapel Hill and a member of the board of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

You can view Barclay’s talk, as well as the rest of the 2011 ABA seminar series, by registering for the online seminar series.