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Are “experts” part of the problem when it comes to breastfeeding?

Is the professionalisation of breastfeeding doing harm? It’s a question that’s worrying Professor Lesley Barclay, the director of the Northern Rivers University Department of Rural Health.

Lesley Barclay writes:

This last week, I was travelling Australia as a speaker for the Australian Breastfeeding Association (ABA), sharing experience and research with two international speakers from the US and UNICEF and a local colleague. There were hundreds of dedicated breastfeeding counselors, lactation consultants, midwives and physicians to listen to us in audiences from in Hobart, Melbourne, Canberra and Brisbane.

We were talking about one of our most important public health activities. Breast feeding improves the health of mother and infants well as conveying economic, environmental and social benefits. Infectious diseases are more common in infants not receiving breast milk and chronic disease is more common in adults who were not breast fed. Nearly 300.000 babies are now born  annually in Australia can be protected by breast feeding.

Compared with the US, Australia seems like a breastfeeding paradise: with our free universal services from experienced maternal-child health nurses and midwives and local, health-professionally led mother’s group. Our Breast Feeding help line run by ABA is also unique with thousands of calls answered annually by trained ABA counsellors. Baby Friendly hospitals are becoming more common, and 90% of mothers initiate breastfeeding.

Yet breastfeeding rates decline rapidly and rates of exclusive breastfeeding at around 6 months are hardly higher here than in the US. This is what disturbs me.

My talk was based on a background as a midwife and health services researcher committed to reform in the design and delivery of maternal child health care and rural and remote health.  I drew on research over a number of years from people such as Virginia Schmied from the University of Western Sydney. She led a recent research metasynthesis published in Birth that helped inform my arguments.

Increasing professionalisation of breastfeeding and rigid implementation of rules appears to be undermining breastfeeding mothers.

Taking this further this point seems to be contributing to iatrogenisis and declining rates. I argued that expert-driven models of breast feeding education and support that are becoming more common can weaken a woman’s confidence and prioritize breast milk delivery to babies over the mother-baby relationship.

Rigid implementation of policies and rules about the use of dummies and rooming-in can have a perverse impact on breastfeeding. They can place staff in opposition to a mother’s need for rest or self determination in relation to her baby.

The trend to use a Lactation Consultant to undertake normal breast feeding is costly and diminishes social support and role modeling from peers. It is analogous to employing an obstetrician in normal birth. The costs and morbidity that has resulted from this practice is now is being addressed by a national policy to reduce intervention in childbirth and address our out of control caesarean section rate.

Mothers need to make well informed decisions about their babies. Rather they appear to be at the mercy of hospital policies or staff and poorly designed services. The need to be expert overrides the sustained relationship shown to facilitate breast feeding. Research shows that a hospital postnatal ward can be a terrible place for a healthy mother-baby dyad to begin their breastfeeding relationship. Shortage of staff, sporadic disconnected interactions do not help.

Women and their babies are being ‘treated’ as machines vulnerable to malfunction, creating iatrogenic illness. 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. Continuity of care models of birth, still received by the minority of women, are ideal

When breastfeeding becomes a professional event, fraught with instructions and prohibitions, we as professionals assert our expert authority and stop women using their own judgment  and knowledge of their babies.

As I said last week, “We have built the perception that breastfeeding is technically challenging and too hard to do without professional help. What happens to a woman’s self-confidence and capacity for decision-making when faced with a conflicting overload of professional help and institution rules?”

We undermine women’s confidence and set them up for breastfeeding failure. 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.

Women need to regain confidence in the ability of their bodies to work in tune with their babies. Mothering — and breastfeeding — is not a technical procedure. It is a relationship between two people that grows with mutual trust and intimacy that has extraordinary benefits for our health, economy and society.

Comments 7

  1. Freddy T says:

    My wife breast fed 2 children. One for 9 weeks and the second for 15 months, although the second child was a reluctant weaner.
    I may be stupid, but it seemed to depend on the baby, and all the help in the world didn’t seem to change things.
    The advice we got for our reluctant first feeder was useless and we got the best advice.
    In reality some babies prefer the bottle. You may not want to hear it but it’s true.
    Our reluctant breast feeding first child is still the same. Can’t be bothered working for things, that’s just the way he is.
    Get over it and support both groups.
    There’s more to motherhood than breast feeding, and you can lead a horse to water…

  2. supernurse says:

    Oh please…this article couldn’t be farther from the truth! As a lactation specialist in the US, I have many thank you notes from patients I have assisted to breastfeed after birth. If we lived in a culture where young girls grew up surrounded by breastfeeding women, perhaps lactation consultants wouldn’t need to do as much educating. My favorite (tongue-in-cheek) quote from this article is, “We undermine womens’ confidence and set them up for breastfeeding failure.” I don’t know where Ms. Sweet is practicing…but, the single most important part of my job…is to BUILD confidence in women (we are the proverbial cheerleaders)! Most of the notes I receive say something like this, “If you hadn’t help me understand that my body is perfectly designed to nourish my baby, I would have stopped breastfeeding!” Maybe, if Ms. Sweet feels SHE is undermining women’s confidence…she needs to rethink her practice. The ONLY part of this article I agree with is the last paragraph. NOW, if you want to discuss how birthing practices impact breastfeeding…I would be glad to hear that one!

  3. supernurse says:

    Oops, the article was amended…I guess it is Ms. Barclay with the problem!

  4. Topender says:

    I’m glad I married an African woman. No problems there. The article is referring to the Australian system and is prompting some analysis of the nature of ‘expert’ models of care and complaining about the fact that the current system does not serve people well. It doesn’t offer too much in the way of solution. The assumption is that all women/families endorse the ‘expert’ model and we know that is increasingly untrue. Supernurse alludes to the core issue, if we grew up with breastfeeding all around us, this would not be a subject for Croakey!! No more silly newspaper articles about women being thrown out of public spaces for giving food to a baby etc etc. Sadly, Freddy T reflects society views as much as anyone, sales of formula (along with disposable nappies) demonstrate their significance. Perhaps Lesley, we all get the public health we deserve!

  5. Haz says:

    I am horrified by this sentence:
    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.

    When my first was born, I needed help with every single feed. I am incredibly thankful for the higher nurse (usually midwife) to patient ratio of the private hospital I went to which meant I got the help I needed – and ended up having an extra day in hospital because of feeding. Not only that, meals appeared, rest times were sacrosanct and dirty plates, dirty nappies, and dust disappeared. This allowed me to focus for just a few days on nothing but the baby and me. (Would that happen at home? Pfffft….!).

    Without that extended stay in hospital, without the round-the-clock professional support, I’d’ve left the hospital with a tin of formula and a load of guilt. As it was, I fed my two children for a total of, um, some years. Which surprises even me, as not only am I far from crunchy-granola, but my guilty secret was that I never intended to breastfeed in the first place!

    In those early days – and the weeks post-hospital when I schlepped between lactation consultants, GP appointments (mastitis) and whatever else, I felt there was plenty of support, and that I had a cheer squad. I will never forget some of those conversations – like when I tentatively asked a lactation consultant “If you were watching me and thinking this is never going to come together, you WOULD tell me, wouldn’t you?”. Most tellingly, from a Tresillian nurse – “We’re not supposed to say this sort of thing, but it’s lovely to see such a big healthy breastfed baby” (child no 2, aged 6 mths).

    Not supposed to! Of course I understand why – the looming spectre of postnatal depression and the inability to change the past for any individual woman can make saying anything that might undermine a formula-feeder dangerous. However the “need” to not be seen to be critical of women who formula feed can be perceived as unsupportive of those women who breastfeed, and formula feeders’ vocal, if not vociferous, self-defence can leave their breastfeeding sisters – and medical professionals – afraid to speak. I was SO grateful for this woman’s supportive yet illicit comment – even though my chunky baby’s rolly thighs and plug-in hands were a dead giveaway for us being on track.

    After the first six weeks the professional cheer squad disappeared and I was left with the amateurs – mother’s group and the clinic. I was in a mother’s group where to say anything positive about breastfeeding (or breastfeeding professionals, or the ABA) was seen as unsupportive (if not attacking) those women who did not. And so it chipped away at the breastfeeders – I recall one breastfeeding mother in the group telling me that she had a can of formula in the cupboard “in case”. Another telling me that she had heard that formula helps babies sleep through so was going to start giving her baby formula as the last feed of the day. Another, that she was going to give her baby formula at some feeds so other members of the family could share in feeding the baby. Each time, I was silent, although I could see the path they were going down and I knew where it would end.

    By four months, I was the only mother still breastfeeding, and was surrounded by what felt like enthusiastic advocates of formula feeding, congratulating themselves on their choice, defending themselves by saying their supply had dropped, there was nothing else they could do etc. I left; it was miserable – there is only so much self-imposed silence and miserable isolation one can take. Especially when the breastfeeding relationship I had established with my child was one that surprised me not only with its simplicity (after those long hard weeks!) but more, and most amazingly, with its joyousness.

    Even in my own extended family, there was no place for “support” out loud. My sister-in-law’s conversion to the bottle at 3 days postpartum, and later, her postnatal depression, meant that even my own mother would say nothing out loud. I knew from a couple of small, on the side comments that she was part of my cheer squad – just a very, very quiet part. My sister also breastfed, but we kept quiet for the sake of my sister-in-law.

    This is an extended anecdote – it is not evidence or data. But to what degree do the “experts” understand what happens in the community once they have walked off the stage? About the women like me, happy, successful breastfeeders feeling like they have to go “underground”. About the culture of protecting formula feeders from “feeling bad” or guilty. About the super secretiveness involved in feeding a child past 12 months, and the slamming that extended breastfeeding gets from broader society. It is only yesterday that one of my closest friends told me that she had breastfed her child until he was three – and I made a similar “confession” – we are all too afraid to speak.

    But how do you change all that?

  6. Jennifer Doggett says:

    In relation to Haz’s comment re her experience at a private hospital, I think it is important to stress that public hospitals also provide support for breastfeeding and have lactation consultants available for women who need their assistance. In fact, being in a public hospital was crucial to establishing breastfeeding with my first child. Because he was born very small he was in the NICU for two weeks after birth. As I was intending to breastfeed I was able to stay in the hospital after I was officially discharged. I was given a bed and meals and was able to be with my baby around the clock to try breastfeeding at the most opportune moments (which were often in the middle of the night!). I also had access to the hospitals electronic breast pumps (anyone who has pumped manually for a fully breast milk fed baby knows how important this is!) and the advice and support of the nurses, midwives lactation consultants and other mums at the hospital in my position who provided invaluable peer support. I spent an additional two weeks in the hospital and it cost me nothing. Had I been in a private hospital I would have either been sent home after discharge and faced the much more difficult task of establishing breastfeeding without being around my baby or incurred a huge bill for a lengthy hospital stay. For both me and my baby, a public hospital was definitely the best choice.

  7. Stakky says:

    I am extremely impressed at the indepth discussion this comment from Ms Barclay has created. I am also often lost for words when people promote the “wonderful”powers of formula feeding and wish I could defend my choice to breastfeed my children 2 and 3 years each. I am especially proud of myself for persisting for so long. I had all sorts of problems at the start, but once it was all sorted I found breastfeeding easy, it was the negative comments, mostly from family, I found harder to deal with. For example, Haven’t you push it a bit far now, you’ll have to feed them at school, and its embarrassing in front of my boyfriend, and so many more. I wish people would be more supportive of a normal and in this society, difficult job to do. As for Lactation consultants making things worse……… I am an LC and I ONLY get worderful comments on the help and support I provide, cause there are so many insensitive people out there that cant keep their comments to themself.

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