Muddled thinking about the concept of “informed choice” are impacting on effective breastfeeding promotion, especially in prenatal education. Many prenatal educators think that information on bottle feeding must be included in their programs to ensure that women have the opportunity to make a reasoned decision about infant feeding. Thus, details on “how to bottle feed” are explained in the belief that a balanced argument has been presented. Let’s look at some of the issues surrounding this issue of breast versus bottle feeding and our roles as educators during the prenatal period.
First, we must recognise that the most acutely affected person, the baby, is not ever consulted about how it is to be fed. For some babies, this may mean having to struggle with poor nutrition during a crucial period of its development, possible allergic reactions that may continue for years, lower immunity and therefore greater susceptibility for infection and the potential for the development of disease in later life that could be life threatening. All of these factors are well documented and researched. Surely the baby has a right to the best possible start in life, and we are obliged to support “the baby’s choice”?
Second, when the baby is born into a culture that is not pro-breastfeeding (and the UK fits this description) advice on its health and well being will largely come from people who have little experience with natural nutrition. A compounding factor is that while most acknowledge that “breast is best”, when the majority of women are bottle feeding there is a strong tendency to find ways of assuaging the guilt engendered. Much of this guilt may be repressed but sometimes it pops up in comments such as “I would have liked to breastfeed but I wasn’t able to because…”
Collective guilt also shows up in the attitude of health professionals. One of the most damaging claims that has been made is that “breastfeeding is a learned art”. This enables a failure to breastfeed to be attributed to a lack of education of the woman rather than to where it belongs – the results of poor support from health professionals. A whole industry is developing , including books and videos, that “educate women” on how to breastfeed. Much emphasis is given to positioning and correct latching techniques as though they are magical answers to any problems that arise. It is all apparently a matter of getting “the right education”.
This is complete nonsense! Breastfeeding is completely instinctive, and is not reliant on any kind of “education” for success. If that were the case, humans would have died out long ago, before books, videos, lactation consultants and all the breastfeeding equipment (nipple shields, breast pumps, breast creams etc) were invented. Yes, there are sometimes problems with breastfeeding, but let’s be clear where they come from: they are not the result of a faulty lactation system or a mother’s lack of “education” – they are likely to be the result of interventions during birth, drugs given in labour, ritual separation of mother and baby and lack of social support postnatally.
Thrust into this climate of uncertainty and confusion about breastfeeding are the formula manufacturers, ever willing to make money out of the situation and ready to cast seeds of doubt about womens’ ability to breastfeed if there is profit to be made. Their selling techniques are subtle and pervasive. Next time you go to a seminar or conference where formula manufacturers have a presence, remember that it will be the babies who are being deprived of optimal nutrition who will pay the price. Your lunch will have been factored into the cost of that baby’s formula and those handouts (posters, notepads, even teaching aids) will be funded by poor women struggling to find money for the formula they have to give their child because they were not supported properly with breastfeeding.
You have a very definite role to play in making sure that women breastfeed as a matter of course. The whole issue is very similar to the arguments against elective Caesarean sections: bottle feeding is not an option that should ever be offered, except in the most dire circumstances. Our babies deserve the best, women must not be compromised by vested interests and our community cannot afford to support the illness, both short and long term, prevalent in the bottle fed child.
Before you can be effective as a promoter of breastfeeding you will need to take a hard look at your own feelings and attitudes around this issue. If you were not able to successfully breastfeed, recognise that it was not your body that let you down, but the system which made it hard for you. Get help for your unresolved grief (not being able to breastfeed is not dissimilar to not being about to have orgasms or give birth easily – it is all part of your sexuality) and avoid inadvertently working your feelings through on other women.
Make sure you have good information about the hazards of bottle feeding. It is not enough to say that “breast is best” – you must present the information about the inadequacies of formula for human infants. Maureen Minchin’s book will help set you straight.
Eliminate all forms of advertising for formula from your practise. Push for the removal of bottles and baby milks from your hospitals and work towards the adoption of “Baby Friendly”environments both before and after birth. Remind your employers at the hospital that giving formula to babies is a treatment, therefore they have a responsibility to make sure that it is administered correctly and appropriately. This will need to be done postnatally on a one-to-one basis with each mother who chooses to bottle feed, before she leaves the hospital. This may be one way of reducing the risk of potential litigation.
If you are leading antenatal classes there are many ways you can explore the topic of infant feeding without breaking the WHO International Code of Marketing of Breastmilk Substitutes. You can explore the issues in a generic sense, looking at attitudes, feelings and practical sources of support, avoiding all specifics of how to make up bottles and other aspects of formula feeding. Women will be unlikely to remember the specific details anyway and this would be better taught on-the-job after the baby’s birth.
Some activities you could include involve adopting a problem solving approach:
- When considering obstetric procedures, drugs for pain in labour, complications and other variations on physiological birth, always include the effects these will have on the breastfeeding relationship and milk production. For example, women are not always told that the pethidine will have a profound effect on the baby’s sucking reflex, or that the epidural anaesthetic can make the baby fractious and difficult to settle. Forceps can give the baby a prolonged headache and oxytocics can increase rates of newborn jaundice. Make sure you have your facts together and the research papers available should parents want to use them.
- Have parents draw up a blueprint for the best possible infant food. What qualities would it need to have? What characteristics would the baby prefer? What would the parents be looking for? Follow up by asking parents to rate breastmilk and formula milk against the criteria they have established. This is a very useful small group activity.
- Ask the group to compile a list of the possible problems they might face in successfully breastfeeding. Encourage them to include social, economic and work-related influences as well as common practical difficulties. Use this is as a basis for developing some solutions and also strategies they can take before the birth to smooth the way postnatally.
- Provide a list of local resources such as support groups and specialised help (lactation consultants etc). Evidence shows that women breastfeed more successfully when they have peer support. Look at the emotional and psychological implications of “failing to breastfeed” and why this may be an outcome for some women. Consider ways of resolving these feelings and learning from the experience gained.
- Class activities and exercises that focus on lifestyle changes, changing responsibilities, sharing the baby care, adapting to new relationships and dealing with stress can all revolve around the baby who is being breastfed.
- Encourage parents to buy one good practical reference book on breastfeeding that they can use as a source of ideas for practical management. Parents often complain of receiving conflicting advice postnatally and one good reference manual can help overcome this by providing consistency within itself.
The rate of breastfeeding in the UK is very low compared with other developed nations. Whilst there are many reasons for this, ambivalence and confusion amongst health professionals and the influences of formula advertising are two major factors. We all have a responsibility to ensure that babies receive the best possible nutrition, and this means taking positive steps to support and encourage women to breastfeed, unequivocally and enthusiastically. Forget “informed choice” – this is not an appropriate area for choice, and if you are unhappy with this strong statement, remember what nature intended for the baby and ask yourself how you can best contribute to this outcome.
Published in The Practising Midwife Vol 3 No 1, Jan 2000