An account of significant events influencing Australian breastfeeding practice over the last 40 years

Impact of the Thompson method on breastfeeding exclusivity and duration: Multi-method design

BACKGROUND

How hospital clinicians facilitate breastfeeding in the first 48-72 h is critical to breastfeeding exclusivity and duration. Mothers who discharge hospital directly breastfeeding are more likely to continue exclusively breastfeeding at 3-months.

OBJECTIVE

To assess the impact of facility-wide implementation of a physiological breastfeeding method (the Thompson method) on direct breastfeeding at hospital discharge and exclusive breastfeeding at 3-months of age.

DESIGN

Multi-method design using interrupted time series analysis and surveys.

SETTING(S)

An Australian tertiary maternity hospital.

PARTICIPANTS

13,667 mother-baby pairs (interrupted time series analysis) and 495 postnatal mothers (surveys).

METHODS

The Thompson method includes cradle position and hold, alignment of mouth-to-nipple, baby-led connection and seal, maternal fine-tuning for symmetry, and leisurely duration. We used a large pre-post implementation dataset and conducted interrupted time series analysis using a 24-month baseline period (January 2016 - December 2017); and a 15-month post-implementation period (April 2018 - June 2019). We recruited a sub-sample of women to complete surveys at hospital discharge and 3-months postpartum. Surveys were primarily used to measure impact of Thompson method on exclusive breastfeeding at 3-months, compared with a baseline survey conducted in same setting.

RESULTS

Following implementation of the Thompson method, the declining trend in direct breastfeeding at hospital discharge was significantly averted by 0.39% each month relative to baseline (95% CI: 0.03% to 0.76%; p = 0.037). While the 3-month exclusive breastfeeding rate in the Thompson group was 3 percentage points higher than the baseline group; this result did not reach statistical significance. However, a subgroup analysis of women who discharged hospital exclusively breastfeeding revealed the relative odds of exclusive breastfeeding at 3-months in the Thompson group was 0.25 (95% CI: 0.17 to 0.38; p < 0.001), significantly better than the baseline group (Z = 3.23, p < 0.01) where the relative odds was only 0.07 (95% CI: 0.03 to 0.19; p < 0.001).

CONCLUSIONS

Implementation of the Thompson method for well mother-baby pairs improved direct breastfeeding trends at hospital discharge. For women who discharged hospital exclusively breastfeeding, exposure to the Thompson method reduced the risk of exclusive breastfeeding discontinuation by 3-months. The positive impact of the method was potentially confounded by partial implementation and a parallel rise in birth interventions which undermine breastfeeding. We recommend strategies to strengthen clinician buy-in to the method, and future research using a cluster randomised trial design.

TWEETABLE ABSTRACT

Facility-wide implementation of the Thompson method improves direct breastfeeding at hospital discharge and predicts breastfeeding exclusivity at 3-months.

Young adults’ perceptions of breastfeeding in public: a focus group study

Objective

To elucidate the perceptions of young Chinese adults aged 18–25 toward adopting breastfeeding in public in Hong Kong Special Administrative Region (Hong Kong), China.

Methods

A descriptive and exploratory study design was adopted. Participants were recruited by convenience sampling. Focus group data were collected from three semi-structured interviews. Responses from 18 participants were audiotaped, transcribed verbatim, coded, and analyzed using content analysis.

Results

Four themes emerged that described the young adults’ perceptions and barriers toward breastfeeding practices: (1) adaptability of self and others, (2) cultural deem and practice, (3) convenience and connection, and (4) education and advocacy. Interestingly, all respondents (male and female) are aware of the benefits of breastfeeding. Their negative perceptions toward breastfeeding initiation and continuation originate from factors that are essentially extraneous to the mother–infant dyads (such as the breadth and intensity of sociopolitical support, the dominant social beliefs and norms, and the inadequacy of breastfeeding education in adolescent years).

Conclusions

In general, the young adult's perception of breastfeeding is dominated by sociopolitical and cultural-related factors. In particular, sexualization of breasts as a deep-rooted belief in the Chinese context negatively affects young adults’ perceptions and limits their breastfeeding practices.

Estimates of Preterm Infants' Breastfeeding Transfer Volumes Are Not Reliably Accurate

BACKGROUND

Adequate human milk nutrition is critical for infant growth and neurodevelopment; however, low milk transfer volumes are common when establishing preterm breastfeeding. Despite clinical assessments of milk transfer volumes at the breast being inaccurate, measurement of feed volume via test weighing is rarely carried out either routinely or in cases where infant weight gain is inadequate.

PURPOSE

To assess the accuracy of the Preterm Breastfeeding Assessment Tool (PBAT) in determining transfer volumes and examine factors associated with PBAT accuracy.

METHODS

Pre/postfeed weights were performed using electronic scales and PBAT scores recorded for 1186 breastfeeds in 60 preterm infants born less than 33/40 and 33 to 39/40 postmenstrual age. Measured milk intake volumes were converted to percent prescribed feed volume and compared with PBAT estimates of milk transfer.

RESULTS

The PBAT is accurate in identifying when no milk is transferred at the breast but not in estimating transfer of half or the full prescribed volume (accuracy 26% and 47%, respectively). Wide ranges of transfer volumes (11-75 mL) were observed within and between infants, and for 20% of breastfeeds, no milk was transferred. Preterm Breastfeeding Assessment Tool accuracy decreased with each 1-week increase in birth gestation (odds ratio = 0.82; 95% confidence interval, 0.71-0.94; P = .004).

IMPLICATIONS FOR PRACTICE

When establishing breastfeeding, test weighing facilitates adequate nutrition by guiding appropriate complementary feeding. For mothers breastfeeding several times per day in preparation for discharge home, test weighing may offer a useful tool for developing maternal confidence in assessing milk transfer. Preterm Breastfeeding Assessment Tool is inaccurate in assessing preterm infants' milk transfer volumes when breastfeeding.

IMPLICATIONS FOR RESEARCH

While studies have typically focused on medically stable infants, test weighing offers a useful tool to examine breastfeeding efficacy and inform nutritional management of preterm infants with complications such as chronic lung and cardiac disease.

Investigating factors associated with success of breastfeeding in first-time mothers undergoing epidural analgesia: a prospective cohort study

Background

We investigated the possible risk factors that could influence the likelihood of breastfeeding at 5 to 9 weeks postpartum with our primary aim being to analyse the associations between psychological vulnerabilities, such as peripartum depression and anxiety, and continued breastfeeding. Our secondary aim was to investigate other non-psychological factors’ influence on continued breastfeeding.

Methods

A prospective cohort study was conducted in KK Women’s and Children’s Hospital in Singapore. Healthy nulliparous parturients at ≥36 weeks gestation with a singleton fetus who received epidural analgesia were recruited. Demographic and anaesthetic data were obtained. Self-reported psychological and pain determinants such as anxiety (State-Trait Anxiety Inventory), depression (Edinburgh Postnatal Depression Scale), stress (Perceived Stress Scale), pain susceptibility (Pain Catastrophizing Scale) and pain perception (McGill Pain Questionnaire) were also recorded at baseline. A phone interview was then performed at 5 to 9 weeks postpartum to obtain information on breastfeeding status.

Results

329 participants were included into this study, of which 263 (79.9%) of them were still breastfeeding at 5 weeks postpartum. Multivariate logistic regression analysis showed that a higher State-Trait Anxiety Inventory score (Adjusted Odds Ratio [AOR] 0.97; 95% Confidence Interval [CI] 0.94, 1.00) at baseline, higher intrapartum blood loss (AOR 0.76; 95% CI 0.61, 0.93), and occurrence of fetal anomalies (AOR 0.15; 95% CI 0.03, 0.72) were associated with reduced likelihood of breastfeeding at 5 to 9 weeks postpartum. Indians (AOR 0.56; 95% CI 0.20, 1.53), Malays (AOR 0.30; 95% CI 0.14, 0.62) and other ethnicities (AOR 0.36; 95% CI 0.16, 0.83) were less likely to continue breastfeeding compared to Chinese participants. On the other hand, receiving any support services on breastfeeding during the participants’ hospital stay was 3.3 times more likely (AOR 3.30; 95% CI 1.21, 9.02) to increase the likelihood of breastfeeding at 5 to 9 weeks postpartum.

Conclusion

We identified 5 independent association factors that could have significant influences on breastfeeding at 5 to 9 weeks postpartum. Healthcare providers could utilize this risk stratification to identify parturients likely to have poorer breastfeeding outcomes and undertake interventions that may help safeguard optimization of breastfeeding outcomes and parturient care.

Trial registration

Clinicaltrials.gov NCT02278601. Registered 26 October 2014.

Electronic supplementary material

The online version of this article (10.1186/s13006-018-0184-7) contains supplementary material, which is available to authorized users.

Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants

BACKGROUND

breastfeeding optimises health outcomes for both mothers and infants. Although most women want to breastfeed, they report commencing infant formula because of nipple pain, unsettled infant behaviour, and infant growth concerns. To date, existing approaches to fit and hold ('latch and positioning') have been demonstrated not to help breastfeeding outcomes, and women report widespread dissatisfaction with the quality of support and conflicting advice they receive. Breast and nipple pain, difficulty with latching and sucking, fussing at the breast, back-arching, marathon feeds, excessively frequent feeds, poor weight gain, breast refusal, and crying due to poor satiety often signal suboptimal positional instability and impaired milk transfer, but may be misdiagnosed as medical conditions. Over the past two decades, there has been an exponential increase in numbers of infants being treated with medications, laser or scissors frenotomy, and manual therapy for unsettled behaviour and breastfeeding difficulty. New approaches to clinical breastfeeding support are urgently required.

METHOD AND RESULTS

we analyse the findings of a literature search of PubMed and MEDLINE databases for ultrasound studies measuring sucking in term and preterm infants. The findings demonstrate that the Stripping Action Model of infant suck during breastfeeding, and the resultant Structural Model of infant suck dysfunction, are inaccurate. Instead, ultrasound data demonstrates the critical role of intra-oral vacuum for milk transfer. We integrate these two-dimensional ultrasound results with clinical experience of the third dimension, volume, to propose a Gestalt Model of the biomechanics of healthy infant suck during breastfeeding. The Gestalt Model hypothesises that optimal intra-oral vacuums and breast tissue volumes are achieved when mother-infant positional stability eliminates conflicting intra-oral vectors, resulting in pain-free, effective milk transfer.

CONCLUSION

the Gestalt Model of the biomechanics of healthy infant suck during breastfeeding opens up the possibility of a new clinical method which may prevent unnecessary medical treatments for breastfeeding problems and related unsettled infant behaviour in early life.

Resistance to breastfeeding: A Foucauldian analysis of breastfeeding support from health professionals

BACKGROUND

Despite widespread consensus regarding the health benefits of breastfeeding, the prevalence of six months exclusive breastfeeding is very low in developed countries including New Zealand.

AIM

This paper aims to evaluate the role that health professionals play in promoting exclusive breastfeeding in New Zealand.

METHODS

Qualitative research involving face to face postpartum interviews conducted four to six weeks after the birth with 30 new mothers who lived in New Zealand and had identified in a short antenatal questionnaire that they intended to practice exclusive breastfeeding for six months. Themes related to exclusive breastfeeding support from health professionals were extracted from the interview transcripts and interpreted using Foucault's ideas about governmentality and bio-power.

RESULTS

Four themes related to the quality of health care support were identified in the interview transcripts. 'Breastfeeding self-efficacy support from the community midwives', 'mothers need to know more about breastfeeding during pregnancy', 'experiencing difficulties breastfeeding' as well as 'pressure and resistance to breastfeeding'.

DISCUSSION

Most mothers in this research spoke about feeling pressured to breastfeed within the New Zealand health system. However, the participating mothers acknowledged the effective support that they had received from community midwives who respected their autonomy, strengthened their self-esteem and encouraged them to breastfeed.

CONCLUSION

Negative historical experiences related to the medicalization of infant feeding in Western countries suggests that health professionals need to provide effective skill support for breastfeeding mothers so that mothers do not consider it a form of "quiet coercion" or as an exercise of "power".

Collaboration: A critical exploration of the care continuum

The purpose of this research was to explore the concept of collaboration within a specific healthcare context and to include the perspectives of healthcare users, a position largely lacking in previous studies. In applying a critical theoretical approach, the focus was on, as an exemplar, mothers with newborn babies who had spent more than 48 hr in a special care nursery. Semistructured interviews were undertaken with child health nurses, midwives and mothers. The three key theoretical findings on collaboration generated in the study point to layers of meanings around identity, knowledge and institutions of care. Findings from the interview data analysis were further examined through the lens of key policy documents. The research outcomes indicate that the concept of collaboration serves an important function in healthcare in obscuring the complexities and ambiguities that characterise the care continuum. The study concludes the need for a more critical approach to the assumptions that underlie the language of collaboration and the implications for practice in healthcare.

The Tenth Step of the BFHI: What midwives need to know about optimal support for mothers, post-discharge

This commentary discusses the 10th Step of the Baby-Friendly Hospital Initiative (BFHI), the only step that goes beyond the hospital to provide for the mother to receive breast-feeding support after she returns to the community. The reasons why such support is needed, and how this support has been provided in different settings, will be discussed. Post-discharge support for breast-feeding mothers takes many forms and is optimised when mothers can access both professional and peer support. The mother-baby dyad is best served by the right advice from the right person at the right time. Midwives who assist the new mother with information about easily accessible support in the community enable the care she has received during her short hospital stay and during any midwifery home visiting to continue when she is in an environment that may not be supportive of breast feeding.

The professionalising of breast feeding--where are we a decade on?

This paper is an empirically informed opinion piece revisiting an argument published in Midwifery 10 years ago, that the increasing professionalisation of breast feeding was not supporting women in Australia in sustaining breast feeding. We present the last 10 years of primary research on the topic, explore major policy initiatives and the establishment and growth of lactation consultants in Australia to see if this has made a difference to sustained rates of breast feeding. We present an analysis of the only consistently collected national statistics on breast feeding and compare this with national and state level government data collections from the last decade. We have found that the considerable effort invested in trying to improve duration of breast feeding amongst women in Australia appears to have failed to improve sustained breast-feeding rates. We argue that this situation might be related to losing sight of the embodied nature of breast feeding and the relationships that must exist between the mother and baby, the knowledge and skills women quickly develop, and a loss of woman to woman support. We conclude that midwives have a major role in avoiding us reproducing similar, unintended, negative consequences to those resulting from increasing obstetrician managed normal birth. These include midwifery scrutiny and involvement in policy development and institutional practices and the design of services.