Don’t throw the baby out with the bath water
A new study out of Scotland is making headlines today that current recommendations for 6 months of exclusive breastfeeding are “unrealistic.” It’s an irksome claim that is prompting breastfeeding advocates to suspect another formula-company-funded misinformation campaign designed to mislead mothers and undermine public health.
In fact, however, the Hoddinott paper, which follows a select group of mothers, partners, sisters, and grandmothers from pregnancy to 6 months after birth, offers a great deal of food for thought for those who care about supporting the wellbeing of families in the months after childbirth.
The study’s authors make the case that, despite increased commitment to exclusive breastfeeding in national and international policy, progress has been slow, and few interventions have moved the dial on breastfeeding. The aim of their study, which was funded by the National Health Service, was to ask mothers what would have been helpful to them as their navigated feeding their infants in the first six months.
Several themes come through. Before birth, mothers were unimpressed with classes that demonstrated breastfeeding with dolls and listed the ingredients in breast milk vs formula. One mother said,
Woman: The class on breastfeeding, the midwife or health visitor that did it brought out a doll and, you know, it was like something you would’ve done at playschool, it was quite kind of. you know, made it seem.. I don’t know what the word is I’m looking for [laugh] but it wasn’t practical, it wasn’t kind of realistic. (ID 1040. Antenatal interview)
“The Rules” were another frequent target of criticism – parents were frustrated by all-or-nothing recommendations that asked them to ignore their own judgment to follow what felt like an arbitrary recommendation. They said they would have welcomed an interactive discussion, including parents who had “broken the rules,” prior to birth, who could share realistic stories of what to expect with early parenting.
After birth, mothers craved hands-on support from providers who would take the time to observe an entire feeding. One mother said:
Woman: [describing qualities of the ideal helper] Patience. Tolerance. Listening, listening to you. Showing you without force. Someone that can focus all their attention on you and the baby and the task at hand. (ID 1210. Interview 24 weeks after birth: breastfeeding, with formula introduced at 1 week and solids at 21-24 weeks)
The authors also explored the tension between the long-term risks of formula-feeding and the immediate perceived benefit of stopping breastfeeding:
Woman: I did feel a bit guilty at first [about stopping breastfeeding]. But then I thought well he wasn’t settling and he needs to make sure he’s getting fed and I’ve obviously got to look after myself as well to be able to look after him. (ID 2255. Interview 3 weeks after birth: formula feeding, introduced at 1 week, breastfeeding stopped at 1 week)
For mothers like this one, abstract information about long-term risks and benefits was not helpful — they needed concrete support to navigate the sleep-deprivation of early parenthood.
The authors note that participants encountered “pivotal points” when they felt that the only solution was to stop breastfeeding – and nthat these moments are missed opportunities for health care providers to help mothers navigate difficulties and sustain breastfeeding. They write:
What would make a difference? Our interpretation is that infant feeding care would improve by providing more proactive rather than reactive care, anticipating mismatches between ideals and reality that underlie pivotal points and providing skilled family-centred help to resolve difficulties.
This study is not perfect. The authors invited more than 500 women to participate, and only 72 responded. It’s possible that the women who agreed to join had preconceived notions about breastfeeding that biased their answers, and that the other 400+ women were delighted with their care and breastfed exclusively for six months without encountering any obstacles or resistance. But given the dismal rates of exclusive breastfeeding in the UK, I suspect that there are some real issues out there. Moreover, their findings resonate with a meta-synthesis of qualitative studies that similarly found women valued realistic information and empathetic support, rather than strict rules and didactic instruction.
This study raises a number of provocative questions for all of us who strive to enable mothers to make informed decisions about infant feeding and achieve their personal goals. As the study’s authors comment, “more of the same approach to promoting and supporting breastfeeding would seem unlikely to be effective.”
I encourage you to sit down, with patience and tolerance, and listen to what these mothers are saying. The full text of the BMJ paper is online here:
The full report from the study team is available from HealthScotland:
What do you think would make a difference?
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.