How can midwives facilitate infant feeding choices?

Many research studies have shown breast milk to be the most nutritious, immunologically protective and baby-specific substance with which to feed an infant (Horta and Victora, 2013; National Institute of Health and Care Excellence [NICE], 2006; Rogers et al, 2011; Brown et al, 2011; Lewis, 2012; Hinsliff-Smith et al, 2014; Sheehan et al, 2010). New mothers have been shown to be especially sensitive to negative feedback, and the value-laden “breast is best” message can create a climate of guilt and anxiety for parents who either choose to formula milk feed or who struggle with breastfeeding (Hinsliff-Smith et al, 2014). It is argued here that one of the most important roles of the midwife in facilitating all methods of infant feeding is to ensure that parents will find pleasure in feeding their newborn independently when they are discharged home. There are many factors to consider in achieving this goal. Firstly, midwives must engage in effective communication, taking into account that this comprises both an educative and supportive element. Secondly, midwives should respect the psychological complexities that inform individual infant feeding choices. Finally, the wider healthcare context must be reflected upon by midwives to establish whether current practice is optimal in facilitating women’s decisions. The first factor to consider is effective communication. To be able to feed their baby effectively, women must be armed with practical advice and information surrounding their chosen feeding method. The Nursing and Midwifery Council [NMC] Code (2008) states that midwives must ‘share with people, in a way they can understand, the information they want or need to know about their health’ (p. 3). For formula milk feeders, relevant information might include the importance of sterilising equipment, how to correctly measure milk powder to avoid dehydration or malnutrition, or to avoid warming formula milk in a microwave lest it scald their infant (NICE, 2006). If formula milk feeding is to be facilitated, parents must be aware of how to safely prepare feeds and reduce infection risks. In terms of breastfeeding, whilst it may seem to some new mothers as a ‘secret society’ with hidden rules and complexities, if midwives invest time in educating women, the process can become demystified (Sheehan et al, 2010, p.375). For example, although it is initially timeconsuming to sit with women and explain the principles of effective positioning and attachment in a comprehensible manner, they are more likely to understand how the process works and be able to attach the baby to the breast effectively. Rather than the midwife manipulating the breast into the baby’s mouth, which some women find invasive and inappropriate, a mother learns for herself which methods are most effective (Redshaw and Henderson, 2012). Taking the time to communicate this information is crucial for breastfeeding to be facilitated. Education is vital in facilitating any infant feeding method successfully. However, women must also feel supported in their infant feeding decisions and encouraged to make the experience enjoyable. For example, women in several studies have reported feeling coerced or pushed into continuing breastfeeding, rather than supported to overcome challenges as they present (HinsliffSmith et al, 2014; Henderson and Redshaw, 2011; Redshaw and Henderson, 2012). For formula milk feeders too, it is imperative that they feel encouraged, confident and competent. Sheehan et al (2010) document reports by women that they have felt judged by midwives for deciding to formula milk feed, and even that information surrounding formula milk feeding is ‘withheld’ from them (p. 377). In encouraging formula milk feeders, midwives face a conflict: as health professionals they must promote breastfeeding as the optimal feeding method, but as advocates for women’s choice they must support and respect their decisions (NICE, 2006; NMC Code, 2008). The NICE guidelines on infant feeding seem to value the former aspect of midwives’ roles in preference to the latter. Health professionals are urged to support breastfeeding by creating environments conducive to lactation, reassuring mothers that their milk supply is sufficient and discussing feeding efficacy at each point of contact (NICE, 2006). Conversely, midwives are simply advised to inform formula milk feeders of how to prepare milk safely. NICE make no reference to encouragement for formula milk feeders. Whilst NICE are not actively advocating that midwives fail to take account of the emotional wellbeing of formula milk feeders, the study of Sheehan et al (2010) seems to suggest that the guidelines are perhaps being interpreted by some midwives in this rather punitive way. This is compounded by the paucity of information on how to make formula feeding enjoyable and rewarding for parents and their babies. Many of the benefits of skin-to-skin contact, for example, are not exclusive to breastfeeding, but the overwhelming majority of the literature surrounding the topic conflates the two. In reality, the benefits of neonatal thermoregulation, cardiac stability and increased maternal-infant attachment, can be enjoyed by formula milk feeders as well as breastfeeders (Bigelow et al, 2014; Bigelow et al, 2012; Moore et al, 2012; Takahashi et al, 2011). Leaflets could be available on postnatal wards to encourage formula milk feeders to establish close bodily contact with their babies. However, the emotional aspect of formula milk feeding seems to be largely overlooked by midwives and guidelines, focusing instead on more technical aspects. Communication is the foundation for successful infant feeding; if women are unaware of how to safely feed their baby, or do not feel supported in their chosen method, they will not feel confident in their abilities. Whilst midwives are “the experts” in effective feeding, part of their role is to pass on this expertise to women so that upon discharge they are empowered and independent in their feeding. The second factor a midwife must consider in facilitating infant feeding choices is how to treat the women in their care as individuals. The Department of Health [DoH] Changing Childbirth report (1993) urges midwives to ‘listen to what people say they want, do not assume’ (p.7). It is widely documented that certain groups are more likely to favour certain infant feeding methods over others. Cultural, social or familial influences can strongly inform decisions surrounding infant feeding. From a sociological perspective, this information is extremely useful in helping to create policies aimed at overcoming or lessening health inequalities. For example, studies suggest that adolescents are less likely to breastfeed their babies than older mothers (Bowman, 2007). As there has been shown to be a link between adolescent mothers and low birthweight babies or pre-term births, babies born to this demographic would particularly benefit from the high nutritional value and immunological protection offered by breast milk (Gibbs et al, 2012; Rogers et al, 2011). However, the health inequalities likely to be experienced by low birthweight and pre-term babies may be compounded rather than alleviated if formula feeding is favoured by the adolescent mother population. Knowledge of this fact may cause health providers to put in place interventions aimed at reversing this trend. Therefore, it is important to consider the role sociodemographic factors can play in infant feeding decisions. However, it is imperative to acknowledge that certain groups may behave in certain ways, whilst bearing in mind that women within groups are also individuals. For example, if a midwife is caring for an adolescent mother who expresses a wish to breastfeed, the midwife should provide as much support to facilitate this decision as she would to an older mother. The fact that the adolescent is part of a demographic with historically low breastfeeding levels does not mean that she, as an individual, is more likely to cease breastfeeding. Midwives must be able to see the women in their care as individuals, and understand the psychological complexities that can influence decisions. Midwives should have an appreciation of how complex and emotive infant feeding choices can be, and make herself available to explore these feelings with a woman if she wishes. Finally, rather than simply being able to facilitate one woman’s choice, midwives must consider how best to facilitate infant feeding choices in a broader sense. By behaving as reflective practitioners, midwives should examine whether current systems of practice are fit-for-purpose, and whether they could be adapted to maximise positive feeding experiences. For example, many studies have highlighted the detrimental impact that inconsistent advice can have on women requiring breastfeeding support (Sheehan et al, 2010; Henderson and Redshaw, 2011; Brown et al, 2011; Redshaw and Henderson, 2012). In one study some women were given directly conflicting advice on effective attachment, which left them feeling confused and vulnerable (Henderson and Redshaw, 2011). All members of the multiprofessional team should act as ‘lifelong learners’ and keep up-to-date with the latest evidence-based research, and there should be consistency in message transmission (Maclean, 2011, p.47). NICE (2006) recommends that all healthcare institutions should implement a standardised policy to encourage breastfeeding, with the Baby Friendly Initiative (BFI) as a minimum. The BFI was established by the United Nations International Children’s Emergency Fund (UNICEF) in order to increase breastfeeding initiation and duration, and to promote positive parent-infant relationships. One of BFI’s aims is to create an educated workforce through a series of structured breastfeeding programmes, to ensure message consistency (UNICEF BFI, 2013). In a contemporary healthcare context in which continuity of care is difficult to achieve, this allows women equal access to evidence-based support. Although BFI promotes consistency of support for breastfeeders, some have criticised the initiative for being too rigid and inflexible (Sheehan et al, 2010). Whilst this argument is certainly not in line with BFI’s intentions, it is possible that if their steps to successful breastfeeding are reduced to a skeleton of meaning due to time constraints placed on midwives, women may perceive that they are simply being given a list of rules to follow. Midwives must consider how the service can adapt to overcome this potential problem. Whilst resource constraints may not allow for more breastfeeding specialist midwives on postnatal wards, perhaps BFI trained volunteers could be available. There is no simple solution to this difficulty, but midwives must analyse whether practices are being implemented in the intended manner. Other practices can be more easily rectified if reflected upon. Studies have demonstrated that the importance of privacy to new mothers can be overlooked by midwives (Hinsliff-Smith et al, 2014; Redshaw and Henderson, 2012). Midwives often communicate with women on an extremely personal level. There is a risk of overlooking how little control women have over their bodies in a hospital setting, and some women may not be comfortable exposing their breasts in front of midwives. NICE guidelines (2006) state that breastfeeding progress should be assessed and documented. Whilst it is vital to ensure correct attachment and positioning to establish successful breastfeeding, informed consent must be gained rather than midwives coercing women through assumption. It is also important that women have control over their curtains and that midwives ask permission to enter. Women in one study reported that midwives ‘preferred curtains open in the morning’ (Redshaw and Henderson, 2012, p.25). Midwives must reflect upon whether institutional practices could potentially damage women’s desire to breastfeed. If a woman feels exposed and vulnerable, the extent to which her infant feeding decision is being facilitated is questionable. As autonomous practitioners it is important that midwives interpret guidelines in a reflective manner. For example, NICE guidelines (2006) urge midwives to ensure that breastfeeding is initiated ‘as soon as possible’ after delivery (p.21). This may lead to some midwives engaging in interventionist behaviours to establish feeding. However, there is evidence to suggest that through a series of reflexes neonates will self-attach to their mother’s breast if left in undisturbed skin-to-skin contact on their mother’s abdomen following delivery (Righard and Alade, 1990). If this process is interrupted by midwives attempting to manoeuvre the baby themselves into an institutionally accepted position, this undermines the baby’s natural instincts and may hinder the initial breastfeed. Whilst more up-to-date and systematic research is required to consolidate these findings, no negative consequences of undisturbed skin-to-skin contact have been found (Moore et al, 2012). Further, evidence suggests that the process of neonatal counter-regulation means that the urgency to initiate the first feed may be overstated. Babies often feed ‘infrequently in the first 24-48 hours after birth’, but can utilise stores of brown fat by conversion into glucose and therefore energy (UNICEF BFI, 2010, p. 1). In healthy, full-term neonates this is an entirely normal physiological process which prevents the baby from becoming hypoglycaemic. Therefore, whilst NICE guidelines (2006) implore midwives to ensure that breastfeeding is initiated within the hour, midwives are ultimately obliged to follow the NMC Code (2008) which requires delivery of care ‘based on the best available evidence’ (p.6). The best available evidence in this case seems to suggest that intervening in an initial feed may disrupt beneficial reflexive processes, and that there is no clinical need for a baby to feed within an hour of delivery. Midwives should observe the principle of non-maleficence and should “first, do no harm”; a strong, evidence-based reason should be required to interfere, rather than to not interfere (Jansen et al, 2013). The midwife must reflect upon whether intervention is necessary or potentially harmful. In conclusion, it is essential that women experience communication that is consistent, correct and confidence-boosting. Women must feel that whether breastfeeding or formula milk feeding they can enjoy nurturing and nourishing their child. This involves midwives creating a supportive, nonjudgmental relationship with the women in their care so that infant feeding can be initiated as smoothly as possible. Midwives must exercise empathy rather than prejudgment when assisting women with infant feeding, showing understanding of social or familial pressures whilst maintaining a view of the woman as an individual, with specific needs and preferences. Listening to what women are saying, rather than assuming, is key. Health professionals must work as a team to ensure that the messages being delivered are consistent, no matter who is delivering care, and initiatives such as BFI can aid institutions in providing a standardised framework. Midwives must exercise reflective judgement when considering their practice. Simple changes could make a great difference to the ways in which women perceive their postnatal care. It is only acceptable to uphold the status quo when all new mothers are entirely satisfied with infant feeding support. Otherwise, midwives should constantly be striving to improve the service for the women in their care. Overall, a midwife’s aim should be to establish infant feeding as an enjoyable, rewarding experience for the mother and her new baby. 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