In Australia, roughly 90 per cent of mothers will initiate breastfeeding in hospital. But many will struggle in the early days and by week 12 that number drops to 64 per cent. The World Health Organization (WHO) recommends breastfeeding for two years, with exclusive breastfeeding for the first six months, but at this age only half of Australian babies are on the breast. Whether it’s due to the system letting us down or our 21st century lifestyle and our right to choose, we have arrived at a point where breastfeeding is considered just one of the methods of baby nourishment rather than the next essential step in the reproductive cycle.
Modern society
As much as we acknowledge that breastfeeding is best, Australians don’t make a habit of sitting around the campfire with our kindred women and children, learning how to do it. “It’s not socially acceptable to mosey over and have a good, close look,” says Robyn Noble, lactation consultant in a Brisbane private practice. “I see women who really have very little idea at all about how to hold a baby for a breastfeed.” She says the Australian Breastfeeding Association (ABA) and its group meetings provide a protected, tribal environment for breastfeeding women, helping to making this “visually learned art” more accessible.
Our tribal ancestors would tell us it’s an art that is handed down through the generations. “Women who breastfeed are more likely to have been breastfed themselves,” says Professor Yvonne Hauck from the School of Population Health at the University of Western Australia. “They’re getting support from their mothers and they can see that they had the benefit and they want to pass that on to their child.” However, in reality, today’s parent faces many social, economic and emotional challenges that are not conducive to a breastfeeding or tribal culture, such as the need for some mothers to return to work quickly after birth, being separated from the support of extended family and geographical isolation.
The physical breast itself represents a societal and emotional challenge for some. The ABA’s handbook, Breastfeeding…Naturally, explains: “In Western culture, the breast is an erotic symbol rather than a symbol of nurture. This can create quite a mental hurdle for some women who are considering breastfeeding or trying to breastfeed.” It continues, “The symbol of the feeding bottle to represent a baby is as pervasive in our culture as the golden arches.”
The same can’t be said for other developed cultures. In Scandinavia, government policies of long, paid parental leave have fostered an environment that is totally supportive of breastfeeding. “It’s basically putting out the message that we see this as really important as a public health issue,” says Hauck. “So not only do they have incredibly fantastic initiation rates, but they have got these great prevalence rates.”
Great expectations
We often hear pregnant women say they will breastfeed if they can or if they have enough milk. “Already in pregnancy, there’s this uncertainty that maybe they won’t be able to do it,” says Caroline Homer, Professor of Midwifery at the University of Technology, Sydney. “In lots of countries it’s just accepted — you’re a woman, you’ve had a baby, of course you’ll be able to breastfeed, no question about it.” Homer acknowledges, though, that we live in a modern society where we value our right to make choices and what’s important is helping women make informed, supported decisions.
With the right support, many women can overcome the common challenges in the early days, such as sore and cracked nipples, mastitis and perceived low milk supply. “The problem is when they don’t expect it,” says Hauck, who argues that the preconception that breastfeeding is easy because it’s natural causes difficulties for many women. “They start thinking, ‘What’s wrong with me? Why isn’t this really easy?’ rather than understanding that it’s actually very common … what we really need to do is make sure you have enough support.”
Even the support of our peers is crucial. Hauck’s research has shown that mothers surrounded by breastfeeding women will have stronger intentions to breastfeed for longer and are more likely to persevere. “Those women don’t necessarily have an easier time but they have this strong intention to continue to do it,” she explains.
The mums’ marketplace
Infant formula, peristaltic teats, bottle warmers … whatever your bottle feeding needs, there’s a convenient product available on the retail market. Scientific development of these products means that, in Australia at least, where we have clean water supply, they are considered safe and appropriate alternatives to breastfeeding. However, the debate remains as to whether the way they’re being marketed is influencing a woman’s decision to stop breastfeeding early — or bypass it altogether.
In 1981, the WHO issued the International Code of Marketing of Breast-milk Substitutes, which in the interest of protecting breastfeeding globally, urges “member countries to review sales promotion activities on baby foods and to introduce appropriate remedial measures”. In Australia, a voluntary, self-regulatory agreement was established to observe the WHO code, including the direction that infant formula is not to be directly advertised to the general public.
But some argue there is still much work to be done. “The world of commerce has really made the most of its opportunity with this,” says Noble. “Typically, paediatric journals, for instance, will have ads for formula in them,” she says. “You’ll hear paediatricians say to mothers that there’s no difference between breastfeeding and artificial feeding — that’s actually the proposition that as a society we’ve been sold about artificially feeding our babies.”
The advertising of toddler formula is allowed in Australia and prominent displays of infant formula in supermarkets ensure that brand and product awareness remains strong.
Modern-day maternity
In Australia, about 99 per cent of mothers will give birth, and therefore start their journey as a parent, in a hospital. We love our nurses and midwives, and many women profess adoration for their obstetricians, too. But, with a caesarean rate that is double the WHO recommended rate of 15 per cent, Australian obstetrics has been the subject of intense scrutiny in recent years.
Homer believes we have introduced rigidity into our hospitals for what should be a natural process, and this has not assisted our breastfeeding rates. “We’ve had rules that have come and gone around keeping mothers and babies together or not together. We’ve had rules about timing of breastfeeding, how often you do it, how long you do it, how you should position the baby. I think we’ve created a whole lot of complexities in hospitals that are probably unnecessary and haven’t helped.”
In 1991, the WHO and UNICEF launched the Baby Friendly Hospital Initiative (BFHI), which aims to improve the role of maternity services in order to protect, promote and support breastfeeding. There are now 67 BFHI-accredited health facilities around Australia. “It means their midwives and doctors have had to undergo several hours a year of exclusive breastfeeding education and that the policies and practices of the hospital need to be consistent,” says Homer. But she admits that even the best BFHI-accredited hospitals can still have an inconsistent approach to breastfeeding, as everybody has their own views and experience on the subject.
Labour of love
The experience of most women during labour is one of excruciating pain, and analgesia can be a welcome relief. There is research to suggest, however, that pain relief, particularly pethidine, can hinder a baby’s ability to breastfeed.
“It absolutely flattens the baby’s normal suck response behaviour,” says Noble. Homer agrees that pethidine administered at the wrong stage of labour, and some forms of epidural, will make the baby dozy at a time when they need to be mastering a new and vital skill. “We know when babies are first born, they’re quite alert … breastfeeding in that early hour or so, when the baby is still awake, makes a difference to long-term breastfeeding duration rates.”
Homer insists, though, that with the right care immediately after birth, pain relief during labour does not have to mean the end of breastfeeding. “For lots of women, epidural is what they need and what they choose,” she says. “[We need to be] thinking about, once the baby is born, what’s the best way to manage the situation that this woman is now in, making that the baby and mother are close together.”
Birth
The simple act of keeping mother and baby together immediately after birth can affect long-term breastfeeding. “The research shows that skin-to-skin contact in the first 24 hours is what’s important,” says Homer. “Most of us believe, in practice, it’s earlier than that.” She says that, in a South American study, several newborn babies were placed low on their mother’s abdomen after birth and observed. Within the hour, the babies wriggled up to the breast by themselves and attached for a feed. “If I hadn’t actually seen it I wouldn’t believe it was possible,” she says.
In many situations, however, there are interruptions that prevent that special moment, such as illness of the baby or mother. Babies born by caesarean section are often immediately removed from the surgical theatre to prevent them falling ill. “The theatres are particularly cold and it’s awkward when a woman’s being sutured to have baby on her chest,” says Homer. “So most places are trying to get mother and baby together in the recovery room.”
It is while mother and baby are still in hospital that another potential problem occurs. Noble says many health professionals will push the back of the baby’s head onto the breast when trying to encourage those first feeds. “It’s an act of sabotage as far as optimal breastfeeding goes,” she says. “It would have to be one of the greatest causes of nipple damage and painful breastfeeds that you can get.”
Postnatal care
Nipple damage is just one of the hurdles many new mums will face in those crucial weeks after the birth. “The figures are saying that if you manage to get to 12 weeks, you are highly likely to continue. The first 12 weeks are the danger zone,” says Noble. It appears, though, that the level of support and care during this period is lacking. Homer describes Australian postnatal care as appalling when compared to some developed countries. In the UK and Scandinavia, midwives visit new mothers in the home regularly for the first six weeks, after which there is a seamless handover to a child health nurse. “[In Australia] we put an awful lot of energy and time into antenatal care; we do not do the same for postnatal care. Once the baby is born, we give you a couple of days postnatal care, then off you go. That’s not enough.”
Our most common gripe is that each health professional tells new mums something different about breastfeeding, complicating what is already a confusing issue at a vulnerable time. “Every piece of research you look at around postnatal care, women will say, ‘Yeah, it was good, but I got 25 different ways of doing things and it drove me crazy.’ [There is] inconsistent information, inconsistent support,” says Homer.
Of particular concern is the lack of support for women from rural areas, who are sent back to often quite isolated communities. Noble compares it to “throwing women out of planes without parachutes”. Even with the excellent, dedicated service of the ABA and other child health centres such as Tresillian and Karitane, it may be several days before a mother can receive face-to-face assistance. Often, we only seek these services once things have already started to go awry.
Whatever the cause of our breastfeeding blunders, our best chance for beating the odds lies with our pregnant women and new mothers, and it’s within our power to give them individual support. Perhaps it’s not that hard to be part of a tribe after all.
10 tips for successful breastfeeding
- Learn the skill early — attend a breastfeeding class while you’re pregnant. While it’s not the same as the real thing, it is the perfect way to start your apprenticeship.
- Create your own tribe — talk to other mums about their expectations and their experience and watch them breastfeed.
- Call on the experts — book in early with a private or hospital lactation consultant to get the first feeds right.
- Educate your partner about breastfeeding — they can be the best source of emotional and practical support for you, around the clock.
- Join the club — the Australian Breastfeeding Association’s nominal subscription fee gives you access to regular meetings and a wealth of knowledge and support.
- Listen to your body — if an attachment feels wrong, stop and retry until you get it right. Your nipples will thank you.
- Relax — your body will find it hard to let down any milk if you’re tense or anxious. Deep breathing and relaxation will restore your strength and confidence.
- Call on the experts (again) — if feeding is still proving difficult, try a breastfeeding support service in your area (ask your GP or child heath clinic) or call a helpline (try Tresillian or the ABA).
- Look after yourself — making milk is hard on your body! Take time out to put your feet up to avoid getting exhausted. Plus, keep an eye out for the symptoms of mastitis and see your GP urgently if they appear.
- Enjoy yourself — feeding is a beautiful way to stop and smell the roses. Use the time to chat to a friend, catch up on some TV or admire your little one’s features.
Norwegian knowhow
If there was a breastfeeding benchmark today, Norway would be it. It’s a far-away land of fjords and family-friendly government policy, where 99 per cent of mothers initiate breastfeeding in hospital and 80 per cent are still going at six months.
It’s not hard to see why. Norway’s leave policy document reads like a working female’s fantasy: 44 weeks parental leave on full pay (or 54 weeks on 80 per cent pay) that can be shared between the parents. Six weeks of this leave is reserved for the father. Parents are also entitled to up to one additional year’s unpaid leave for each child and, importantly, mothers may take paid time off from work to breastfeed.
Add to this the prohibition of formula advertising and the emergence of Ammehjelpen — a voluntary network of women supporting and promoting breastfeeding — and you have a culture that not only accepts breastfeeding but expects it. Little wonder they are world leaders when it comes to swapping the bottle for the breast.
