Readings in Infant Feeding Practices-4 The Obstetrician's Opportunity: Translating "breast is best" from theory to practice
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Readings in Infant Feeding Practices-4
The Obstetrician's Opportunity: Translating
"breast is best" from theory to practice - extracted text
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SDA-RF-CH-1.23
UNICEF
Regional Office for South Central Asia
73 Lodi Estate, New Delhi-110003
Readings in Infant Feeding Practices-4
The Obstetrician's Opportunity: Translating
"breast is best" from theory to practice
BEVERLY WINIKOFF, M.D., M.P.H.
EDWARD C. BAER, B.A.
New York, New York
The superiority of breast-feeding to artificial feeding of infants has been well established for
nutritional, biochemical, antiinfective, psychological, economic, and contraceptive reasons. The
promotion of breast-feeding should, therefore, be a high-priority concern of health workers. Both
provision of information and support to expectant mothers and changes in hospital routines in the
perinatal period have been shown capable of dramatically increasing the incidence and duration of
breast-feeding in populations studied. Moreover, these interventions are quite specific, effective,
manageable, and affordable. Obstetricians have a special responsibility and capacity to promote
breast-feeding given their contact with women throughout pregnancy and their influence on hospital
birth routines. A greater commitment on the part of obstetricians to promote breast-feeding could
accelerate and extend the current shift back to breast-feeding, to the benefit of mothers and their
babies in all socioeconomic groups. (Am. J. Obstet. Gynecol. 138:105, 1980.)
Each year, scientific evidence provides increasing
justification for promoting breast-feeding. While the
protective effects of breast-feeding against common
infections are especially important in unsanitary envi
ronments, mounting clinical and epidemiologic evi
dence demonstrates distinct advantages, even in mod
ern industrialized societies.1-3 However, theoretical
knowledge of the superiority of breast-feeding has sel
dom been translated into a commitment to promote it
in the community.
Re-examination of attempts to promote breast-feed
ing demonstrates, nevertheless, that enlightened medi
cal practice can substantially increase the prevalence
and length of successful lactation. The common per
ception that trends away from breast-feeding are an
From The Population Council.
Reprint requests: Beverly Winikoff, M.D., The Population
Council, One Dag Hammarskjold Plaza, New York, New
York 10017.
inevitable part of “modernization” and are difficult to
reverse does not seem to be accurate. In fact, there
appears to be a series of specific, manageable steps that
can increase markedly the incidence and duration of
breast-feeding, and, as a bonus, they are not costly to
implement. It seems that there are no special secrets
to promotion of breast-feeding; what a rational per
son would think might work does, in fact, work. (See
Table I.)
Finally, analysis of the key points for intervention
demonstrates that most are closely linked to obstetric
practice and attitudes for several reasons. First, in the
United States, obstetricians bear central responsibility
for delivering prenatal care directly to patients, for set
ting medical standards for maternity services, and
for providing public information on pregnancy and
childbirth. Second, obstetricians generally are charged
with supervising and monitoring the performance of
labor and delivery services in hospitals. Third, obstetric
attitudes and practices act on the mother throughout
2
Table I. Summary of selected intervention program effects on incidence and duration of breast-feeding
Place
Sourer
Information and support:
Brimblccombe and
Cullen” (1977)
Exeter. England
Burne55 (1976)
Oxford. England
Coles and Vai man92
(1976)
CreeryM (1973)
Harrow, England
Cheltenham. England
Type of intervention
Sample size
Time of
measurement
Education of midwives and
health visitors on consul
tant unit (L)
Continuity of care by
stable. familiar health
team (L)
Hospital-based education
program (L)
Education of health pro
fessionals (L)
Education of fathers (P)
562
Hospital discharge
73
6 weeks post
partum
±1.300
Hospital discharge
4,950
Hospital discharge
23
De Chateau el al.®7
(1977)
Halpern el al.25
(1972)
Umea, Sweden
Dallas, Texas
Positive attitudes of pedia
tricians (C)
4.753
Kirk” (1978)
Edinburgh, Scotland
Education by doctors and
nurses (L)
278
Meyer13 (1968)
U.S. hospitals
Hospital programs to pro
mote breast-feeding
(unspecified (C)
2.951
hospitals
Rawlins94 (1978)
Indiana
*
Sjolin’1 (1976)
Uppsala, Sweden
Obstetric counseling and
group support (L)
Mass media education (L)
Sloper et a).29
(1977)
Sloper et al.30
(1975)
Smart and Bam
ford54 (1976)
Waller45 (1946)
Oxford, England
Education of midwives and
health visitors (L)
Education of midwives (L)
256
Oxford, England
Manchester, England
Woolwich. England
Changes in hospital routines:
Bjerre and EkeMalmo, Sweden
lund” (1970)
Clavano” (1978)
Baguio, Philippines
De Chateau65
(1976)
Umea, Sweden
De Chateau et al.67
(1977)
Umea, Sweden
Jackson et al.7’
(1956)
Johnson66 (1976)
Klaus and Kennell'“ (1976)
New Haven, Connecti
cut
Seattle, Washington
Guatemala City, Guatemala (Social Security
Hospital)
Duration
*
Initiation
1 mo post partum
4 mo post partum
Hospital discharge
435
Hospital discharge
5 mo post partum
1 mo post partum
2 mo post partum
4 mo post partum
6 mo post partum
Hospital discharge
5 mo post partum
Hospital discharge
Education of hospital staff
(L)
Daily expression of colos
trum (P)
1,448
Hospital discharge
Rooming-in (P)
3,214
Hospital discharge
10.000
♦
Rooming-in. no supple
mentary food (L)
Skin-to-skin contact and
immediate suckling after
birth (P)
No routine weighings and
no supplementary food
(P)
Skin-to-skin contact and
immediate suckling after
birth (P)
Rooming-in (P)
Immediate suckling after
birth (P)
Immediate suckling after
birth (P)
C — Cross-sectional. L — Longitudinal. P = Prospective controlled.
*Not given.
200
40
3 mo post partum
390
Duration
42
Duration
282
Duration
12
2 mo post partum
40
6 mo post partum
12 mo post
partum
medico friend circle
[organization & bulletin office]
326, V Main, 1st Block
Koramangala, Bangalore-560 034
% Breast-feeding
or duration of
breast-feeding
before inter
vention (or in
control group)
% Breast-feeding
or duration of
breast-feeding
after inter
vention (or in
control group)
Net increase in %
breast-feeding
or duration
of breast-feeding
42.5%
32.0%
Jh
69.0%
54.7%
69.4%
45 0%
64.0%
75 days (fathers
135 days (fathers
informed)
not informed)
29.1% (pediatri
14.5% (pediatri
cians indiffer
cians not indif
ferent)
ent about
breast-feeding)
68.5%
43 6%
26.9%
43.5%
37.0%
10.3%
18.0% (overall
34.8% (for hos
pital with
rate)
breast-feeding
program)
65.0%
33.0%
52.0%
15.0%
78.8%
39.5%
69.0%
22.1%
39.4%
6.0%
15.4%
1.0%
37.0%
52.0%
43.0%
23.0%
37.0%
14.0%
A
37.0%
14.7%
19.0%
60 days
14.6%
24.9%
37.0%
26.7%
16.8%
32.0%
37.0%
49.3%
45.9%
33.4%
14.4%
15.0%
20.0%
23.0%
37.0%
44.0%
7.0%
56.0%
83.0%
27.0%
76.0%
93.0%
17.0%
26.4%
87.3%
60.9%
26.0%
58.0%
32.0%
42 days
95 days
53 days
108 days
175 days
67 days
1.77 mo
3.14 mo
1.37 mo
16.6%
100.0%
83.4%
16.7%
0.0%
52.9%
29.4%
3
pregnancy, labor, and delivery and have a marked
influence on initial infant feeding choices. Despite the
appealing logic of assuming that the neonate is the pe
diatrician's patient, obstetricians simply cannot divest
themselves of the responsibility for promoting appro
priate patterns of infant feeding. The evidence sug
gests that obstetric specialists have, along with unique
responsibilities, unmatched opportunities and abilities
to perform this service well.
Why promote breast-feeding?
Significant nutritional, immunologic, biochemical,
antiallergenic. psychological, contraceptive, and eco-'
nomic advantages of breast-feeding have been well
documented in the scientific literature.'”’ A wide range
of clinical experiments has established the value of
breast-feeding in preventing gastroenteritis, respira
tory tract infections, necrotizing enterocolitis, otitis
media, shigella infections, hypocalcemia, hypernatre
mia, obesity, cow's milk allergy, asthma, and a variety of
other diseases. The psychological implications of suc
cessful mother-child bonding, a process enhanced by
breast-feeding, are only now beginning to be under
stood and appear crucial to harmonious early devel
opment." Because of this extensive documentation,
endorsements of the crucial importance of breast
feeding have come from the World Health Organiza
tion, the International Pediatrics Association, the
British Department of Health and Social Security, and
the American Academy of Pediatrics, which recently
stated: "Ideally, breast milk should be practically the
only source of nutrients for the first four to six months
for most infants."
The history of breast-feeding patterns in indus
trialized countries has shown two major trends since
(he early twentieth century. Breast-feeding in the
United States and Western Europe began to decline
dramatically in the 1930s and 1940s, this trend lasting
through the 1960s.'2 In 1966, only 18% of mothers in
the United Slates were exclusively breast-feeding their
babies upon hospital discharge.13 In the last several
years, however, breast-feeding in the industrialized
countries has enjoyed a new surge of popularity." Un
like the situation in most developing countries, where
the rich breast-feed the least, in industrialized nations
middle- and upper-class mothers breast-feed more and
longer than the poor. It may be that, as with the adop
tion of artificial feeding earlier in this century,-the poor
will follow the rich classes back to breast-feeding in the
future. However, the possibility that the shift back to
breast-feeding may eventually include the poor is no
justification for failing to hasten the process, especially
since breast-feeding among low-income groups in the
United States continues to be extremelv rare.'3
4
Table I—Cont'd
Source
Place
Changes in hospital routines—Conl’d:
McBryde74 (1951)
Durham, North Carolina
Salariya et al.6"
Dundee. England
(1978)
Type of intervention
Rooming-in (L)
Sample size
Time o]
measurement
2,067
Hospital discharge
Early initiation and increased frequency of
breast-feeding (P)
Immediate suckling after
birth (P)
11 1
Duration
68
Duration
Immediate suckling after
birth (P)
40
Duration
Immediate suckling and
rooming-in (P)
200
2 mo post partum
Sheffield, England
Education and changes in
hospital routines (L)
11,658
Svejcar96 (1977)
Prague. Czechoslovakia
*
Wong9’(1975)
Singapore
Education of nursing staff
and demand feeding
and rooming-in (L)
Support of breast-feeding
by hospital staff and no
supplementary feeding
(P)
Intention to breastfeed
1 mo post partum
Hospital discharge
*
Initiation
Sosa et al.6* (1976)
Sousa et al.75
(1974)
Combined programs:
Jepson et al.90
(1976)
Guatemala City, Guatcmala (Roosevelt Hospital)
Guatemala City, Guatemala (Social Security
Hospital)
Pelotas, Brazil
Traditional versus modern societies: The need for
planned interventions
Lactation is almost always successful in traditional
societies in contrast with the high rates of lactation fail
ure often reported in industrialized societies?- 16 In
traditional societies, no alternative to breast-feeding is
perceived or practiced. Pressures to bottle-feed (e.g..
commercial advertising of milk substitutes, misguided
advice of medical practitioners, supplantation of the
breast's nurturing functions by its erotic role) are con
spicuously absent. In short, breast-feeding is viewed as
a routine, socially acceptable, necessary activity ex
pected of every mother of every new baby. In Western
industrial societies, the development of nutritionally
acceptable artificial substitutes has meant that breast
feeding is no longer essential for infant survival. The
high value placed on "scientific feeding," the indiffer
ence or ignorance of the health professions, the desire
of some women for lime away from infant care, and the
aggressive promotion of infant formula combine to
demote the importance of breast-feeding. In fact,
breast-feeding has been explicitly rejected as embar
rassing, crude, and primitive.'7The lack of emotional and social support for breast
feeding in industrialized culture is held by many to be a
key determinant of breast-feeding failure.IB-20 Marked
declines in breast-feeding have been observed among
immigrants to Western cultures,"’ reflecting the acces
sibility of substitutes and the generally low esteem for
breast-feeding in modern society. In modern. Western
ized culture, with reinforcement for breast-feeding
generally lacking in the social system, it falls to health
care institutions to provide information as well as sur
rogates for the supportive atmosphere of traditional
societies. Breast-feeding promotion programs in indus
trialized countries operate within a context in which
bottle-feeding is treated as an appropriate infant feed
ing method and where infant formula is made available
to all mothers on the shelf of the local store as well as
distributed free to the hospital nursery. Nevertheless,
even under conditions typical of advanced societies, fo
cused institutional programs show significant measures
of success in the promotion of breast-feeding.
Factors affecting breast-feeding
Personal and social correlates of breast-feeding.
The most significant correlate of successful breast
feeding is social class. Virtually every study of breast
feeding patterns in Western nations in the last 20 years
reveals a clear positive correlation between successful
breast-feeding and higher social class.“■ 2'-:l0 Factors
such as education, which are linked with social class, are
5
% Bread-feeding
or duration of
bread-feeding
before inter
vention (or in
control group)
•
% Bread-feeding
or duration oj
bread-feeding
after inter
vention (or m
control group)
Nel increase in %
bread-feeding
or duration
of breast-feeding
58.57
23.5%
77 days
182 days
105 days
109 days
159 days
50 days
104 days
196 days
92 days
27.0%
77.07
50.0%
36.07
59.07
23.0%
21.87
67.0%
27.77
81.07
5.9%
14.0%
47.0%
72.07
25.0%
similarly correlated.11,22 For other factors, such as par
ity, maternal age, marital status, how the mother her
self was fed as an infant, place of residence, place of
delivery, difficulty of delivery, sex of infant, ethnic
group, etc., the evidence is at best suggestive and at
’worst contradictory.
A composite profile of women most likely to breast
feed identifies those who are from middle and upper
classes, well educated, older than 25 years, married, and
were themselves breast-fed. Pat ily is a confusing factor:
Some studies show no independent influence,30, 31
while others suggest that primiparous women are more
likelv to initiate breast-feeding23 but also are more
likely to give it up.20 For multiparous women, a strong
correlation exists between how previous children were
fed and how the subsequent child is fed.26 This corre
lation suggests the crucial importance of supporting a
primiparous patient for successful breast-feeding as it
will influence feeding patterns for later children as
well.26, 32
The mother's decision. Many women have already
decided on the method of infant feeding before preg
nancy21, 26 and almost all have decided by the last
trimester of pregnancy. Thus, information given dur
ing obstetric care is much more important than any
pediatric pleadings after birth. Mothers report re
ceiving information and advice from a variety of
sources.17, 21, 24, 30 The reasons women choose to start
breast-feeding center around the recognition of health
benefits for the baby, the closeness possible between
mother and child, and the belief that it is “the natural
thing" to do. The reasons for which mothers bottle
feed also ate complex, but the proportion of these
mothers expressing fear and embarrassment about
breast-feeding is high (in some cases over 50% ).17, 24,26
Also of concern is the proportion of women who are
unaware of any dif ferences between breast- and bottle
feeding or who have simply never thought about
breast-feeding.33
Although many writers glibly state that salaried work
causes women to reject breast-feeding, the contention
that work is a major impediment is not sustained by
empirical evidence.17,24,3,~36 No study of the impact of
work on breast-feeding suggests this as an important
consideration for more than 10% of the population
surveyed, and it is frequently for far less.17, ”■21, 24, 28, 37
There is some evidence that working women breast
feed more than nonworking women.35, 36
The most commonly cited reason for mothers who
are nursing to stop is that the milk “dries up" or is
insufficient.17, ”• 24, 30 Helsing39 emphasizes that this
answer is commonly cited because it is socially accept
able. Applebaum10 and Gurney41 stress that where milk
is, in fact, insufficient this is frequently caused by inap
propriate advice and faulty technique—usually the in
troduction of supplementary feeds that reduce sucking
on the breast and thus reduce milk secretion. Other
factors which have been noted as contributing to dis
continuation are fatigue, sore nipples, and medical ad
vice to discontinue breast-feeding.
Interventions
A recent resurgence of breast-feeding in West
ern countries has come about, in part, as a result of
three forces: the activities of breast-feeding support
groups'9, 42; a “back-to-nature movement," in which
consumers spurn artificial or processed foods; and
growing appreciation of and advocacy for breast
feeding by some health professionals. In the 1970s,
there was a virtual explosion of interest in breast
feeding: More than 150 papers on human milk and the
process of breast-feeding appeared in the last 9 months
of 1976 alone.43 Beyond these general phanomena are
specific program efforts undertaken in an attempt to
increase the incidence and duration of breast-feeding.
Some of these have taken place at the national level
(e.g., in England and Sweden) while most were im
plemented at the hospital level. Overall, there is im
pressive evidence demonstrating that rates of breast
feeding can be increased.
6
Medical interventions which have proved effective in
promoting breast-feeding can be divided into two
categories: those that supply information and support
and those that change hospital routines so as to facili
tate the successful establishment of lactation. In many
cases, successful programs to increase breast-feeding
have involved both types of actions, which seem to have
the potential for interacting synergistically. Indeed, in
creased information on the importance of breast
feeding may influence hospital staff to change hospital
routines because the staff itself has become more sup
portive of breast-feeding. Such positive staff attitudes
also may be translated into direct support of patient
decisions to breast-feed even without a formal patient
education program. To the extent that the data permit.
however, information/supporl programs and hospital
routine changes will be considered separately since
they have different practical implications: The first set
of activities involves changes in the behavior of per son
nel toward patients while the second involves changes
in the management of hospital services.
Information and support. Theoretically, activities
providing information and those providing support
arc different from each other and separable in their
effects. In fact, the two types of activities are almost
impossible to separate. In the first place, all educational
exchanges involve nonformal. unspoken messages of
support from health personnel to patients, and these
messages seem valuable in promoting breast-feeding.
Second, imparting information to patients requires in
creased staff time in direct patient contact, and this too
has emotionally supportive effects. Finally, training of
staff so that they can teach patients has the effect of
increasing staff knowledge—and often enthusiasm—
about the benefits of breast-feeding. The impact of any
educational program may thus derive as much from
the support offered as from the technical information
given. The close interaction of information and sup
port is demonstrated in studies where the efficacy of
technical advice in solving common problems can be
evaluated separately from the effect of the intervention
in toto in promoting lactation. For example, while
breast-feeding classes do favor a longer duration of
nursing, the breast preparation taught in those very
classes, contrary to expectations, is not effective in pre
venting sore nipples or breast engorgement/' Simi
larly, it was found that it was not nipple preparation
per se but the extra support and encouragement pro
vided to an experimental group that accounted for
their better nursing experiences.‘5- 10
Some of the earliest programs to increase breast
feeding consisted of combined information and sup
port. Because artificial feeding resulted in catastrophic
episodes of infectious diseases.'7
physicians in the
first decades of the twentieth century were concerned
with promoting breast-feeding in order to reduce in
fant morbidity and mortality. One of the first programs
to promote breast-feeding took place in Minneapolis,
Minnesota.77 There, two doctors established a Breast
feeding Investigation Bureau, which enlisted the coop
eration of every physician in the city, assigned a nurse
to visit the home of every mother within 3 weeks of a
birth, and solicited information by mail on each nurs
ing mother and her child. While no comparisons can be
made with breast-feeding rates before the Bureau's
work began, the doctors cite a fall in the city’s infant
mortality rate from 81 to 65 per thousand as evidence!
of their success in promoting breast-feeding. Among’
babies born in the first 5 months of 1919. 96% were
breast-fed after 2 months, and 72% were still receiving
breast milk after 9 months. A similar system was
adopted in Nassau County, New York, in 1923.52 Nine
tenths of the mothers breast-fed their infants for 1
month and two thirds continued for at least 7 months.
Again, while no comparative data from earlier years
are available, the authors note that the infant mortality
rate in this group was 49 per thousand, as compared
with 70, 67, and 78 per thousand in the immediatelypreceding years of 1920, 1921, and 1922.
A wide variety of recent studies confirms the princi
ple that mothers afforded reliable information from
health workers are more likely to initiate and continue
breast-feeding. Wood53 notes that women choosing
breast-feeding have the largest number of sources of
information, in one sample, only a third of new moth
ers felt that hospital nurses provided useful informal
lion, yet among those women who felt that the infor
mation they had received was useful, 79% were still
breast-feeding at 3 months post partum, more than
twice the average for the whole group. The main dif
ference between those who were successful at breast
feeding and those who were not seemed to be the
women’s access to support and information.22
Another striking finding is that information and ed
ucation programs aimed at hospital staff are often as
effective in increasing breast-feeding rates as direct
education of new parents. Promoting breast-feeding
among relevant health personnel seems to be the first
step in creating a service atmosphere that is truly con
ducive to successful lactation. This argues for better
training of all staff and reinforcement of breast
feeding messages from obstetricians, in particular, to
other personnel with whom they work. A single ward
seminar designed to increase the interest in and knowl
edge of the nursing staff succeeded in increasing the
proportion of mothers breast-feeding on hospital dis-
medico friend circle
1'00 & U" ,
326
9avVmMain, 1stb Block
e in
26.
Ofamangala, Bangalore.560034
charge from 14% to 37%.'" When this study was re
peated 2 years later,29 the proportion of women
breast-feeding on discharge had risen to 52%, with a
longer duration of breast-feeding and a noticeable
delay in the introduction of solid foods. Smart and
Bamford51 noted an increase in breast-feeding upon
hospital discharge from 37% to 44%. over a few months
without an) specific patient-oriented program. They
attributed this rise in part to the fact that their own
research had stimulated great interest in breast-feeding
among the health staff.
Continuity of medical care also seems to be an impor
tant factor in providing the background of information
pnd support necessary for successful lactation. Two
groups, both seen in the same antenatal clinic, were
noted to have markedly different breast-feeding rates.
Among those seeing general practitioners who per
sonally provided all the prenatal, labor and delivery,
and postnatal care for each of their patients, breast
feeding was practiced bv 69% at 6 weeks post partum.
Those seen by specialist obstetricians, on the other
hand, were given prenatal care by a shared, group
practice arrangement and were seen in the hospital by
a number of different house physicians. This second
group had a breast-feeding rate of only 32% al 6 weeks
post partum.55
Physicians as individuals can exercise a great deal of
influence on breast-feeding, both positively56 and neg
atively.22 An American obstetrician in Indiana pro
motes breast-feeding by convening her patients in an
informal group discussion. Each expectant mother is
assigned a “counselor" who herself is an experienced
Jareast-feeding mother. In 2 years, the hospital breast
feeding rate of these patients increased from 33% to
65%. and the proportion breast-feeding at 5 months
increased from 15% to 52%.57 Haider59 shows that with
a minimal investment of time in a group discussion
conducted by a physician for 20 to 30 parents, 80% of
those attending breast-feed as compared with only 20%
of those who do not attend. When talks are given in
smaller groups, 90% of women breast-feed in the hos
pital and 80% continue for at least 3 months.
Although it is clear that good information and sup
port networks can increase the prevalence of successful
breast-feeding, the proportion of women receiving lit
tle or no advice from professional sources is surprisingly
high. Many women are acutely aware of the failure of
professional sources to provide information.21-14, 59 In
one group of mothers, only 8% had been given specific
information on breast-feeding at their antenatal
clinic28; of these, 91% attempted to breast-feed, far
more than those given little or no advice. Seventy-eight
percent of bottle-feeders reported they had been given
no encouragement to breast-feed; even among
breast-feeders, only 42% said they had been encour
aged to do so. Even when women acknowledge pro
fessional support, most rank the help of the doctor
below that of the nurse or midwife.59 Women appar
ently feel that doctors are frequently unsupportive, H
and if doctors are discouraging about breast-feeding,
mothers will be discouraged from attempting it.”
Taken together, all these studies provide evidence for
the general hypothesis that information and support
can significantly enhance the chances for successful
breast-feeding. While the types, timing, and duration
of programs will need to be tailored to suit each lo
cale, it is clear that health personnel play an impor
tant role in fostering the conditions in which breast
feeding can flourish.
Changes in hospital routines. Technological prog
ress has permitted enormous advances in the care of
sick and abnormal infants, but routine hospital proce
dures for healthy infants, in many cases, appear to in
terfere with normal physical and psychological pro
cesses." In particular, many hospital routines have
been shown to decrease the likelihood of successful ini
tiation and maintenance of lactation. Revision of these
routines can increase the incidence of positive breast
feeding experiences. Anything that restricts feeding
contact during the first 10 days of life is associated with
less successful breast-feeding.61 Included are sep
aration of mother and baby after birth, introduction of
prelacteal feeds and/or supplementary feeds, feeding
on a rigid schedule, and drugs administered in labor.
Immediate breast-feeding and skin-to-skin contact. A num
ber of studies point toward the primary importance of
sustained intimate contact between mother and infant
in the first postpartum days.'0, "• “• “ Mothers permit
ted such contact show greater affectionate behavior,
adaptability, and independence when compared to
mothers deprived of this experience. There is a sig
nificant and growing body of evidence suggesting that
skin-to-skin contact between mother and child imme
diately after delivery strengthens the mother-child
bond, one consequence of which is greater likelihood
of prolonged breast-feeding. Studies from distinctively
different population groups support this hypothesis.
In Guatemala, the pioneering work of Klaus and Kennell10 demonstrated that 45 minutes of contact after
birth was significantly associated with a greater dura
tion of breast-feeding, up to 100% longer than in the
control group. Infants in the experimental group
suffered fewer episodes of infectious disease, and in
one trial infants in the experimental group gained
more weight at 6 months and 1 year than the control
group infants.*4
8
De Chateau65 found that providing 30 minutes of
skin-to-skin contact immediately after birth resulted in
a breast-feeding rate of 58% at 3 months, as compared
with 26% in the control group. The effect of early
mother-child contact was also demonstrated by a small
controlled trial in the United States.66 Of 12 mothers
intending to breast-feed, six were given their babies
shortly after birth while the other six were given their
babies 16 hours later. z\t 2 months post partum. all six
of the early contact mothers were still breast-feeding,
while only one of six in the delayed contact group was
doing so. Similar results were found in a Swedish study
of the effect of early skin-to-skin contact and suckit g
on breast-feeding patterns.67 The median duration of
breast-feeding in the early contact group was 175 days.
over 2 months more than the median duration of 108
days in the control group mothers. Significant benefits
of early initiation of breast-feeding combined with in
creased frequency of nursing also has been demon
strated.66 A group of mothers who nursed early and
breast-fed every 2 hours continued feeding for a me
dian of 182 days, as compared to 77 days for a group
who initiated breast-feeding later and fed only every 4
hours. The early initiation of sucking was found more
important in prolonging breast-feeding than the in
creased frequency of feeding.
While immediate skin-to-skin contact and early suck
ing are powerful promoters of successful breast
feeding, cross-cultural studies show that in very tradi
tional societies, where breast-feeding is the norm,
successful lactation may occur without immediate suck
ing.20- 69 In such situations, however, many other ex
tremely powerful stimuli to successful breast-feeding
also are at work. This lends weight to the conclusion
that "early contact may be a simple way of promoting
breast-feeding for some mother-infant pairs cared for
in the highly technical and 'unnatural' environment of
today's delivery units."70 The diversity of possible
pathways to successful breast-feeding—and mother
ing—speaks to the flexibility and adaptability of the
human species. Still, there need to be mechanisms by
which mother-infant attachment is facilitated, whether
these are built into the general social structure or spe
cifically provided by a technologically oriented birth
care system.
Rooming-in. Rooming-in (keeping the newborn infant
within easy reach of the mother 24 hours a day) also
has been shown to increase the likelihood of successful
breast-feeding. A detailed 'analysis of the effects of
rooming-in on the incidence and duration of breast
feeding showed that as late as 3 to 4 months after deliv
ery about 1% times as many “rooming-in” mothers as
“nursery” mothers were still breast-feeding.71 Similar
results were reported by Lind and Jadcrling72 in 1964
in a trial with 172 rooming-in mothers and 172 control
mothers. In a Swedish study of 3,214 mothers. 93% of
mothers who had had rooming-in were breast-feeding
upon hospital discharge as compared with 76% of
mothers from the regular maternity ward.73 Mothers
who had rooming-in also showed more self-confidence
in the management of their children and sought advice
less often in the first month post partum. The institu
tion of compulsory rooming-in in Durham, North
Carolina, boosted the breast-feeding rate there from
35% to 58.5% upon hospital discharge.71 While no sig
nificant correlation was found between room arrange
ments and intention to breast-feed, two thirds of thosA
mothers who were still breast-feeding at 3 months posr
partum had had rooming-in arrangements while more
than half of the mothers who had stopped breast
feeding at this time had not.2-’
Programmatically, the advantages of early contact
between mother and child and 24-hour rooming-in arc
often combined. Sousa and associates75 showed that
among mother-infant pairs who enjoyed these ar
rangements, 77% were still breast-feeding at 2 months
post partum. as compared to 27% of the control group
in which mothers and babies were separated according
to hospital routine. In the Philippines, Clavano76 reor
ganized the postpartum ward of one hospital to pro
vide rooming-in for all mothers and newborn infants.
Mothers were given their infants within 2 hours after
birth and were not separated from their infants while
in the hospital. In addition to an increase in the per
centage of women breast-feeding from 26.4% to
87.3%, in the infant population there was a reducuo^
in the morbidity rate of 56.8% and in the mortality rat?
of 44.9%, mostly because of decreases in septicemia
and diarrhea.
As demonstrated by the decline in morbidity and
mortality in Clavano's76 study, rooming-in appears to
offer substantial benefits in reduction in the risk of
infection. It also may reduce the amount of staff time
needed for infant care since the mothers provide most
of the care for their own babies. It seems to increase the
confidence and independence of mothers'0, 62 and,
above all, to foster a healthy relationship between
mother and newborn infant in the sensitive period fol
lowing birth. Furthermore, the rooming-in model has
been demonstrated to be overwhelmingly preferred by
mothers.62
Demand feeding with no supplementary bottles. A close
concomitant of early initiation of breast-feeding and
rooming-in is demand feeding, in which the baby is
allowed to nurse whenever it desires rather than ac
cording to a rigid schedule. Apparently, demand feed
9
ing can be instituted as part of the normal hospital
routine with little difficulty.” Consistently, breast
feeding has been found more likely to be successful
among infants on demand feeding.78- ” A sensitive.
dynamic interaction between mother and child governs
the normal hormonal control of milk secretion (prolac
tin) and milk ejection (oxytocin). Feeding according to
a rigid schedule inhibits natural interactions and the
early successful establishment of lactation1’0 at least
three separate ways. Interference with normal hungcr/saticty cycles in the infant may disrupt the mecha
nisms for regulation of food intake; decreased fre
quency and effectiveness of infant sucking will
•terfcrc with prolactin production and, therefore, the
milk supply of the mother; finally, rigid routines in
crease anxiety in the mother and interfere with milk
ejection.
Evidence is mounting that the mechanisms for self
regulation of food intake in the infant are sensitive
and effective.1" Both small-for-date and large-for-date
breast-led infants tend to "grow back into the charts"
more quickly than their bottle-fed counterparts.
These same mechanisms of intake regulation, when
undisturbed, also have been reported to decrease the
likelihood of infantile obesity.K1
The routine administration of prelactcal feeds and
subsequent complementary feeds to the breast-fed in
fant reduce the infant's sucking on the breast and
hence the secretion of milk.59 Furthermore, since suck
ing a bottle is a fundamentally different process from
sucking a breast, complementary feeds also may un
dermine lactation by making the infant's sucking mo^bps inappropriate for breast-feeding. This hypothesis
iT supported by a study of 884 infants in which the
duration of breast-feeding was doubled if supplemen
tary feedings were introduced by spoon rather than
bottle.81
The undesirable effects of complementary feeding
include not only the physiologic inhibition of milk se
cretion due to decreased sucking but also the implicit
undermining message to the mother: The staff feels
she cannot meet the baby's needs by herself. This mes
sage also may be conveyed by other rigid procedures
with equally deleterious effects. This may be the mech
anism whereby routine weighing of babies before and
after each breast-feeding inhibits successful lactation.67
Abandonment of this routine was found to reduce
early lactation failure, probably by decreasing anxiety
that blocks the milk "let-down reflex." In fact, prelacteal feeds have been found useless to prevent weight
loss in the newborn infant; what they more commonly
prevent is successful breast-feeding.70 Supplementary
feeds may have the same effect. When women com
plain of insufficient milk, a problem with many possible
causes, they are often counseled to add artificial feeds.
The offer by physicians of a "prescription" of bottle
supplements without investigation of the cause of the
mother's complaint is an unusual deviation from nor
mal standards of medical care. In a study of patient
physician interactions, it was found that women who
complained of “insufficient milk" were counseled to
add complementary feeds, with the result that breast
feeding stopped within 2 weeks in every case.55
Drugs. Certain drugs given to mothers may inhibit the
establishment of successful lactation.80 Brazelton85- ““
demonstrated that the ability to breast-feed successfully
was impaired by the administration of barbiturates to
the mother during labor. On the first postpartum day,
30% of heavily medicated mothers were considered
“effective" breast-feeders, as compared to 65% of
lightly medicated mothers. It took 5 to 6 days before
this difference disappeared. Using more precise mea
surements of sucking, Kron and co-workers86 demon
strated that central nervous system depressants given
during labor reduce the amount of nutritive sucking by
the infant. Decreased sucking leads to decreased con
sumption of milk by the infant and decreased stimulus
for milk production in the mother. Medication given in
labor can inhibit sucking and render feeding interac
tions more difficult for up to 10 days post partum.87 It
has also been shown that ergonovine maleate interferes
with prolactin secretion and thus may decrease milk
production.88
Preliminary evidence from Thailand indicates that
the timing of postpartum sterilization may have sig
nificant effects on lactation, either because of the anxi
ety and stress caused by the procedure or because of
the use of sedation and anesthesia.83 Milk production
was apparently not affected in women undergoing op
eration within 24 hours of delivery, but there was a
significant lowering of milk volume at both 7 and 14
days post partum in mothers whose tubal ligations were
done 4 to 6 days after delivery. The investigators
hypothesize that the lactation-suppressing effects of
drugs and anxiety are most critically significant if im
posed on mothers during the time when milk produc
tion begins and lactation is being established.
The evidence demonstrates that certain routine med
ical practices and procedures can have deleterious ef
fects on lactation. The effects of many other practices
on breast-feeding, even those thought to be totally un
related to lactation, remain completely unknown. Cer
tainly, it cannot be assumed that routine patient
care practices are entirely benign in their effects on
mother-infant interactions. Until questions are asked
about the effects of routine practices, however, their
10
exact impacts on nursing performance will never be
come evident.
Information combined with changed hospital prac
tices. Just as combining information and support en
hances breast-feeding more than either one alone,
combining both with sensible hospital routines should
act as an even more powerful promoter of breast
feeding success. In Sheffield, England, a package of
changes, including better education of doctors and
nurses, public education, antenatal classes, modifica
tion of hospital routines, and better home help to
mothers from midwives and nurses, was instituted. The
result was an increase in the proportion of women in
tending to breast-feed from 36% in 1973 to 59% in
1976.90 In a prospective study in Singapore, Wong91
showed that 72% of mothers initiated breast-feeding in
a ward where nurses and midwives enthusiastically
promoted it and where supplementary feeding was
halted. In a comparable ward, where staff had no more
than routine interest and powdered infant formula was
supplied on demand, only 47% of mothers initiated
breast-feeding.
Implications for actions to promote breast-feeding
Breast-feeding is a complex interaction between
mother and infant that can be enhanced or inhibited by
a wide range of social, psychological, and physiologic
factors. While the overall social context and the value
that each culture places on breast-feeding may ulti
mately determine infant feeding patterns, medical per
sonnel have both the responsibility and the opportunity
to increase the status of breast-feeding within the pro
fessions as well as in the community. The evidence
cited above demonstrates that breast-feeding promo
tion activities work in all social environments and
systematically raise the prevalence and duration of
breast-feeding, whether these were initially low or high.
For example, in Sweden, a high breast-feeding rate was
made almost universal (76% to 93%), whereas in Brazil
interventions converted a low rate into a high rate (27%
to 77%).”• ”
In this paper, interventions that have been shown to
be successful are classified into two broad categories:
information and support and hospital routines. In
general, the first type of change is most likely to meet
with the greatest acceptance from health workers. Few
members of the health team have vested interests in
“no education,” and none would oppose actively the
provision of information. The absence of education in
most hospitals is usually ascribed to heavy patient loads,
but this is merely a reflection of its low priority in most
service delivery systems: With a medical orientation
toward unusual pathology, normal lactation is seldom
found “interesting.”
In the case of hospital routines, however, the situa
tion is different: “Hospital routines are often much
more geared to the requirements of the institution than
to the needs of mother and infant."27 Changing rou
tines, even when the overwhelming weight of evidence
shows clear benefits to patients, encounters initial resis
tance from those accustomed to standard procedures.
Ironically, although it is easier to gain administrative
and staff support for educational activities than for
institutional changes, the latter may be easier and
cheaper to accomplish. Education programs require
ongoing staff commitment, repeated effort every ye^
and recurrent funds. Changes in hospital practices, on
the other hand, generally can be accomplished in a
short period of time, need be done only once, do not
require continued efforts, and often end up saving
money.76
Given the current pressures on medical care to (1)
encourage self-reliance, (2) promote physical and psy
chological health through preventive rather than cura
tive medicine, and (3) contain costs, the promotion of
breast-feeding offers exciting possibilities. In the im
mediate future there are a number of steps that can
contribute to the promotion of breast-feeding, and
these do not require unreasonable amounts of staff
time, expensive pedagogic materials, or elaborate ar
chitectural renovations. The data suggest that even min
imal expressions of interest by physicians in breast
feeding (e.g., ward seminars, research projects, simply
inquiring how many women are breast-feeding) can
make a difference. Similarly, reorganization of hosp^t
routines in the perinatal period, with an eye to minimiz
ing interventions and practices of questionable value,
could enhance the well-being of mother and infant.
The burden of responsibility for promoting breast
feeding has fallen on pediatricians because they treat
illnesses arising out of improper feeding. Good pedi
atric guidance is, of course, essential if breast-feeding is
to be sustained through minor physical and psycholog
ical problems. However, if a mother is not convinced of
the superiority of breast-feeding, she may not even try
it in the first instance: Positive attitudes toward breast
feeding are correlated with significantly higher success
rates than ambivalent or negative attitudes. By the time
a pediatrician sees the mother, it is too late to provide
the information and encouragement that enhance the
chances for successful nursing. It is the obstetrician
who, in fact, has the greatest potential for increasing
the prevalence and duration of breast-feeding.
Because of the state of the art of breast-feeding re
1
11
search, there are certain important things which we do
not yet understand. Although it is clear that both
information/support and appropriate medical prac
tices will increase breast-feeding rates, we do not yet
know anything about optimum mixes of these two sorts
of interventions. It is not known how much of each
must be provided for maximum efficacy and efficiency
of program operation, although it is clear that there is
some substitutability of effect. For example, while late
initiation of breast-feeding is not detrimental to suc
cessful lactation in certain traditional societies, it obvi
ously has adverse effects in Western-oriented medical
systems. How much support and education would be
□pessary to overcome this barrier to nursing? Would it
^Kasier and/or cheaper to make universal changes in
postdelivery' practices than to provide information and
support networks? The answers to such questions are
not immediately available.
Neither is it known how to compute the exact costs
and/or savings involved in revision of hospital routines.
Although it is clearly not an expensive proposition, and
may be money saving, to make such changes, figures
applicable to United States institutions with different
service provision patterns are not available at present.
Both the financial and service mix questions have im
portant implications for rational program develop
ment, and, although the answers arc not yet known,
there is no reason to suppose that they are unknowable.
What is apparent is that staff attitudes and hospital
routines can be structured rather easily and effectively
so that they make important contributions to successful
lactation.
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