Factors which help and hinder breastfeeding

Factors which help and which hinder breastfeeding

Broad Social Factors

In our, western, society, there are some broad social factors which have a huge influence on whether a baby will be breastfed. Some of these are:

  • Socio-economic status of the mother and her family. Put simply, the poorer a mother is, the less likely she is to breastfeed. This is a complete reversal of trends of previous centuries – when rich women had their babies wetnursed, and poor women fed their babies themselves. It is a trend that has been clearly observed since the UK began making detailed surveys on infant feeding in 1975. It is usually attributed to lower socio-economic status being associated with lower levels of education and therefore assumed less understanding of the benefits of breastfeeding. There are clearly other issues at play as well, since use of artificial milk actually began in the wealthier classes, but has ‘trickled down’. Although more research needs to be done to understand the reasons behind this factor, it is acknowledged as a fact by everyone working in breastfeeding support.
  • Mother’s educational level. The higher the level of education attained, the more likely a mother is to breastfeed – this is closely related to the point above.
  • Mother’s occupation and working life. Occupation is also related to socio-economic status – those in professional and managerial roles are more likely to breastfeed than those in manual jobs. But the age of her baby when she returns to work, how many hours per week she returns to work, and whether her workplace offers any facilities for breastfeeding breaks or expressing, also influence the duration of breastfeeding.
  • Mother’s age. Young mothers under 20 are least likely to breastfeed in the UK (less than 51%), while those over 35 are most likely to (84%).
  • Birth order. First time mothers are more likely to breastfeed than mothers having a second or subsequent child, although mothers who had a successful experience feeding a first child are likely to initiate breastfeeding subsequently.
  • Mother’s ethnicity. In the UK, it has been found that about three quarters of white mothers initiate breastfeeding, while the rates for all other ethnic groups are about 9 in 10.[i]

Before and During Pregnancy

One of the main indicators of whether a mother will choose even to try breastfeeding (and then if she does, whether she will be ‘successful’) is how much exposure she has had to it in her life, particularly whether she was herself breastfed. One oft-quoted reference is that most women have decided by the age of sixteen whether or not they will breastfeed prospective children. So, one of the biggest ways to help lay the groundwork for successful breastfeeding pre-delivery is for the mother to have lots of contact with breastfeeding mothers and babies. This will do three things: first, she will learn more about the mechanics of how it works – what a good position and latch can look like. This is the way that breastfeeding was learned in pre-artificial-feeding societies, and remains the norm in many cultures; women learn ‘by osmosis’, unconsciously, by watching breastfeeding happen as part of daily life. Second, it will give the mother confidence in the process – she will see that it works, that babies are happy and healthy, and that the mothers are too. This will help to dispel many of the myths our society has created that discourage breastfeeding. Three, knowing other breastfeeding women will provide the mother with a support network, the pre-existence of which is invaluable should she encounter difficulties. Many women find it much easier to talk to a friend whom they know has had similar experiences, than to phone up a stranger.

The flipside to this is that if a woman has not had a lot of contact with breastfeeding throughout her life, it is likely that she’s been exposed to a lot of myths and unhelpful stereotypes about breastfeeding, which can have a very negative influence on her desire to try it, and her chances of success if she does. For example, some popular culture myths about breastfeeding are (just to name a few): that it always hurts, that the baby is always hungry until the ‘milk comes in’, that breastfed babies do not sleep as well as artificially-fed babies, that it will make her breasts saggy, that there is a high probability she won’t have enough milk. All of these and more may be passed on by mothers and grandmothers, friends, television programmes, and articles in baby magazines, and unfortunately sometimes health professionals. Simultaneously, this mother is receiving a flood of positive information about artificial feeding – that formula fed babies sleep better, gain weight better, that artificial feeding is more convenient and less of a strain on her. And these usually come with insidious attacks on breastfeeding that undermine confidence in it and can seriously hinder successful breastfeeding.

I personally feel that education and preparation for breastfeeding, during pregnancy, can have a significant positive influence. Education can overcome many of the popular myths that are just simply untrue. Surveys have also demonstrated that mothers choose to breastfeed at least in part because they are aware of the health benefits of breastfeeding; therefore it is important that all expectant mothers be given accurate information on the health implications of their feeding choice. The Infant Feeding Survey has also shown that there is a high correlation between intention to feed and initiation of breastfeeding, and further, that women who discussed feeding choice at antenatal appointments and antenatal classes were more likely to intend to feed.

Preparation – talking about good positioning and latch, and watching other mothers feed – will give a mother an idea of what to aim for. And having realistic, accurate ideas of what to expect is key – that breastfeeding is a learned skill for both parties, so just because it may not ‘click’ straight away, doesn’t mean it won’t work, or that feeding for long periods is very normal in a newborn and not an indication that anything is wrong. Women who are armed with this information ahead of time seem more likely to carry on breastfeeding, and to seek help when they need it, than women who just thought it was all supposed to work and then may get flustered when it needs a bit of tweaking. I think this sort of preparation can be delivered either in a formal breastfeeding setting such as a breastfeeding preparation class (run on some NHS and NCT antenatal courses) or attending an LLL meeting, or in less formal settings such as baby cafes and drop-ins that welcome expectant mothers.

Labour and the first 24 hours after birth

One of the biggest issues during labour that can affect breastfeeding is the use of drugs and painkillers. Studies have concluded that mothers who receive pethidine, particularly if it is given close to delivery, give birth to babies with a higher likelihood of sucking and rooting problems, including more crying, fewer breast-seeking behaviours, delayed and depressed rooting, and less sucking. One study found that babies of mothers who received an epidural during labour were less alert, less able to orient themselves, and had less organized movements at the breast, and that these differences were measureable throughout the entire first month of life.[ii]

Apart from drugs, physical interventions (which frequently go hand-in-hand with the drugs) can hinder the establishment of successful breastfeeding. Babies delivered by ventouse or forceps may suffer head or neck trauma that can make it painful to feed.

Cesarean section birth presents a range of potential hinderances to breastfeeding, but it is important to keep in mind that successful nursing remains possible and desirable, no matter how the baby was born. If a general anaesthetic was used, the mother may be unconscious for some time, which can delay the first breastfeed. However many c-sections can be performed with a regional anaesthetic, after which the mother should be able to breastfeed very soon, either in theatre or in the recovery ward.

With any hospital birth, but more so with c-sections and very medicalised births, another potential pitfall is separation of mother and baby. One study found that separation for as little as 20 minutes immediately after birth led to a dramatic fall in effective first feeds. Other studies have linked early separation with shorter overall duration of breastfeeding.[iii]

Modern practices also advise a range of potentially painful procedures for the baby, which can interfere with feeding. Particularly problematic is vigorous suctioning of the mouth and throat – sometimes necessary if the baby has breathing difficulties but sometimes still performed routinely – which can lead to a sore throat and injured vocal cords, making sucking painful. Other procedures include heel sticks, injections, spinal taps, or circumcisions – all of these are painful and may make a baby unreceptive to breastfeeding. However, nursing through these procedures has been shown to have a powerful analgesic effect.[iv]

Finally, the hospital environment in which most women in our society give birth can itself be non-conducive to successful establishment of breastfeeding. What should be an intimate, private bonding moment between mother and baby is all too often rushed, under harsh lights and the interfering stares and interventions of medical personnel – this is not the ideal first-feed scenario. Then, in the hours and perhaps days after birth if the mother remains in hospital, she may have to battle to keep her baby with her, and she will almost certainly be kept awake by the lights, other people, hospital routines and noise… And many hospitals still give babies supplemental bottles, sometimes even against parental wishes. But many women do successfully breastfeed after giving birth in hospital – let’s go back to the beginning.

Ideally, a woman will have thought about breastfeeding and prepared during pregnancy, learning about good positioning, what to expect from her newborn and from herself, and will have written a birth plan that takes into account how best to establish breastfeeding. Not every birth goes to plan, of course, but understanding ahead of time how different scenarios affect breastfeeding can help the mother prepare for whatever happens. Giving birth naturally and without painkillers is the ideal, from the perspective of establishing breastfeeding. When natural childbirth goes well, hormones are released in both the mother and baby that help emotional bonding, and stimulate the rooting and sucking reflex in the baby and the let-down reflex in the mother. These hormones will also help the mother’s uterus to contact – particularly helpful in the case of a c-section delivery. In almost all births, the baby can be delivered straight onto the mother’s stomach. If alert and well, the baby may be left to ‘breast-crawl’ – an amazing feat in which the newborn makes his own way to the nipple! Otherwise the mother can bring him to the breast for the first feed – preferably within just a few minutes of birth. This immediate skin-to-skin contact is vital for the baby’s health, and not only in terms of breastfeeding but also because it helps him regulate his body temperature, and makes sure his skin is colonised by the same bacteria as his mother’s  which some studies suggest can aid in bonding.

The mother may like some guidance at this point, but any assistance should be sensitive and subtle, to help mother and baby get themselves into a good position and attachment, rather than roughly doing it for them. Once a good latch has been achieved, the pair should be left undisturbed for as long as they both want. This is the basic tenant of establishing successful breastfeeding in any circumstance – breastfeeding should be unrestricted and undisturbed, with no limits on frequency or duration of feeds, and intervention only when required and requested. Feeding should be encouraged to happen every 1.5 – 2 hours, if the baby is not already requesting it himself, to avoid dehydration and prevent him from getting frantically hungry, which can make getting a good latch more difficult.

Qualified help should be available to ensure that the latch is good, and provide support if it is not. Midwives, while they have a lot of experience in seeing women breastfeed, often have no actual breastfeeding-specific qualifications, and many have not breastfed their own children. This is why qualified support is so important – mixed messages, however well-meaning, are confusing and detrimental. The help of a well-informed and supportive partner or friend is also invaluable.

Mother and baby should not be separated, and should be allowed to share a bed, safely, if the mother wants to do so. Except in cases of clear medical necessity, the baby should not receive anything other than breastmilk – no supplements of artificial milk, water, or anything else. Where it is medically necessary, supplementation is best offered by means other than a bottle, such as cup or syringe feeding, and preferably by the mother herself or the father. Pacifiers or soothers should be avoided.

To summarize, many things about modern labour, childbirth, and the immediate post-partum period can negatively impact on breastfeeding. The best ways to support the establishment of successful nursing are:

  • good preparation and realistic expectations
  • as natural a labour and childbirth as possible
  • skin-to-skin contact as soon as possible
  • no separation of mother and baby
  • unrestricted, frequent breastfeeding
  • no intervention (supplements, etc)
  • qualified, sensitive support when required.

First month

Although initiation rates of breastfeeding may seem high (78% in England)[v], these rates drop dramatically, with the sharpest decline happening in the first 2-6 weeks of life – by six weeks, the figure is about 50%. This refers to babies receiving any breastmilk. Among mothers who initiated exclusive breastfeeding at birth, the sharpest decline was also seen in the first weeks, leaving just 32% of those babies still exclusively breastfed at six weeks old. What is happening in this first month that has such a deleterious effect on breastfeeding?

Many respondents to the Infant Feeding Survey cited insufficient milk supply as a reason for stopping breastfeeding in the early weeks. As this was a mother questionnaire, it is impossible to know whether they really didn’t have enough milk, but given that only 1-2% of women are physiologically incapable of sufficient milk production, it seems logical to conclude that a large proportion of these women were either misinterpreting the situation (ie, they really did have enough milk, but believed they did not), or that they had insufficient supply due to poor breastfeeding management. The survey also noted that by far the highest proportion of women experiencing feeding difficulties in this period were those who were mix-feeding, breastmilk and supplements. It was not clear whether supplements included expressed breastmilk fed via bottle.

It is very noticeable that in our society there is, immediately after birth in most cases, a huge push to ‘get back to normal’. Parents both seem to think that after a brief period of adjustment, their lives will more or less return to what they were before, only with a baby there as well. Mothers have the added pressure to return to their pre-pregnancy shape and weight. This has contributed to the huge popularity of proscriptive baby-care regimes, which dictate tightly controlled feeding and sleeping times, and so on. All of this is detrimental to the establishment of successful breastfeeding, which requires the demand-and-supply approach of on-cue feeding and relying on the baby’s and the mother’s instincts more than the rule book. But because babies ‘haven’t read the book’, mothers fret that they aren’t getting enough milk – because they are hungry again before their four hours are up, or because they have had their allotted ten minutes of feeding but aren’t satisfied, or because they don’t sleep for as long as expected, or at the ‘right’ times. Because of a wealth of misinformation, many mothers conclude that a baby is unsettled because she doesn’t have enough milk, or because it isn’t good enough. This can lead to supplementation with artificial milk. As soon as supplements are introduced, the demand-and-supply cycle is disturbed, and the risk of supply dropping actually increases. Mothers who are mix-feeding are also at a higher risk of engorgement and blocked ducts, which have themselves been cited as reasons for stopping breastfeeding.

I feel the need to make special note of the current fad for feeding expressed breastmilk via bottle. While still not as popular here as it is in the US, this seems to be gaining in popularity and I find it alarming. There seems to be an serious misunderstanding that the milk is the most important factor in breastfeeding, and therefore bottlefeeding EBM is just as good as breastfeeding from the source. This is simply untrue. Bottlefeeding EBM can still interfere with a mother’s supply, because a pump will never be as efficient as a baby at extracting milk and stimulating supply, not to mention the emotional bonding process which is lost when silicone and glass replace your baby. No matter what is in the bottle, nipple confusion is a real possibility, especially in the early weeks. But rather than discuss at length the reasons not to routinely bottlefeed EBM, we should just point out that there is almost never a good reason to do it, so why would you? Parents often cite the father’s desire to bond with his baby, but people who know babies well know that feeding is only one area, and there are many ways a father can bond closely with his new baby that do not involve a bottle. There are also other ways to help a new mother out and ‘give her a break’.

Even among mothers who do not give supplementary artificial milk or EBM, many mothers are still trying to get their babies onto a strict routine in the early weeks. This is at odds with a baby’s natural pattern of behaviour as he gets to know the world and gets to grips with organising his feeding. As discussed in the section above, one of the main tenents here is unrestricted access to the breast. Breastfeeding must not be scheduled by the clock, and feeds should not be restricted in frequency or duration. It may help to understand that babies’ patterns are likely to be chaotic and changeable over this period, and that they are unlikely to fit neatly into a timetable. Having a partner, friends, or other support on hand who understands this too and can support the mother during this time is invaluable. A partner who grumbles ‘why don’t you just give him a bottle’, when the baby is yet again awake at 2am is eroding a mother’s confidence. But one who gets up with her, rubs her back while she works to get the baby latched on well, tells her what a great job she’s doing and offers to get her a drink of water, is supporting both the mother and the baby, and supporting the establishment of successful breastfeeding.

This dichotomy between support and lack of support can come from all sides. Older female relatives are a particular pitfall – they may be very supportive, or they may chip in with well-meaning but unhelpful comments (‘I fed all of mine formula and they’re fine’). And of course health professionals play a crucial role at this stage. A well-informed HP who is truly supportive of breastfeeding can be a godsend, but equally, a poorly-informed one can undermine a mother’s firmest intentions, for example by questioning weight gain and the baby’s health, or any one of numerous other all-too-common issues.

Another area of concern in the early weeks is feeding in public. Most mothers breastfeed their babies all over the place with no issues, but unfortunately some do still encounter problems, ranging from a disapproving glance all the way to being ejected from public spaces. Often, it is not an actual experience, but merely the fear of one, or potential embarrassment, that worries a mother, and she usually finds that once she’s got out there and starting breastfeeding in public, things do go smoothly.

The list of top reasons cited by mothers who give up breastfeeding within the first two weeks is: insufficient milk, breast or nipple pain, the baby rejecting the breast or refusing to suck, breastfeeding taking too long or being too tiring, the mother being ill, the mother not liking breastfeeding, ‘domestic reasons’ (not clarified, but one assumes this includes care of other children and household work), the baby being ill, difficulty in judging how much milk the baby has had, and that they could not share feeding responsibilities. What is striking from this list, is how many of these factors could be addressed by having access to trained, dedicated breastfeeding support. The worries over milk supply, particularly, could be alleviated by a better understanding of the process, and most problems with breast and nipple pain can be addressed through adjusting attachment and positioning. But this requires specialist support. Other causes of pain and poor feeding such as tongue-tie are often missed unless the mother consults a breastfeeding specialist but, once diagnosed, can be corrected easily and breastfeeding can be successful. What is also striking is that by far the most common place mothers seek advice when they experience breastfeeding problems, at all stages after the immediate post-partum period, is from their health visitor. Unfortunately, the fact that most HVs do not have specialist training means that all too often these women are not getting the support they need. Trained BFCs and IBCLCs did not even make it into the list of common places for support.[vi]

It seems that mothers who are able to adopt a more relaxed approach to the first weeks and months may have fewer problems with breastfeeding, or may perceive fewer things to be a problem. For example, a mother who expects her 4 week old to sleep from 11-8 perceives a problem of wakefulness and unsettledness when he does not. But a mother who expects her 4 week old to feed off and on throughout the night does not perceive a problem. Similarly, a mother expecting a baby to feed four-hourly may think he is hungry and that her milk is insufficient when he wants to cluster feed in the evening. But a mother who isn’t watching the clock and isn’t concerned about routines may not perceive a problem.

Factors that can help breastfeeding at this stage are co-sleeping – because when the baby is close to his mother at night he is likely to feed more (boosting her supply in the crucial 2-5am window when prolactin levels are highest), and she is more likely to pick up on his feeding cues (meaning he doesn’t go hungry). Babywearing or carrying during the daytime can have similar benefits.

In summary, the first month is full of potential pitfalls for breastfeeding, many of which centre around a mother’s idea of what her baby ‘should’ be doing, and trying to get him into a routine or schedule. Physiological problems such as breast and nipple pain are also common. But mothers who are well supported, by well-informed partners, by family and friends with experience of breastfeeding, and with access to good help to overcome such problems if they occur, are most likely to keep nursing their babies.

One month onwards

All of the factors discussed above still apply after one month and the end of the official newborn period, although as time progresses, women are less likely to cite breast refusal as a reason to stop breastfeeding. Support, or lack thereof, from partners, family, friends, and health workers is still absolutely key in how a mother feels about the breastfeeding relationship, and how it will develop.

There does seem to be a strange idea that the biological benefits of breastfeeding only apply for the first six weeks of life. I personally have even heard a GP say this, that there is therefore ‘no reason’ to continue nursing after six weeks. Such unhelpful and astoundingly wrong ideas can obviously hinder a successful breastfeeding experience, particularly as a mother is most likely to encounter something like this if she has approached a health professional for help or advice. If she has taken this step, it is probably because she is having a problem, in which case she is probably feeling even more vulnerable than the already fragile state many new mothers are in. And so it can be devastating to have the issue made light of. I cannot determine the origin of this particular myth, but the only way to fight it is with education and accurate information and support.

There does seem to be some suggestion that women are likely to feed subsequent children for a similar length of time as first or previous children, so if a mother stopped nursing her first at six weeks, she is more likely to stop feeding her second early, as compared to a mother who fed her first for a longer period. In general, many mothers talk about difficulty in tending to older children’s needs while establishing breastfeeding with a young baby – this seems to be a more frequent issue in families with closer age gaps, where the older child is still quite dependant.

As the baby gets older, the mother is also more likely to face pressure to introduce supplements, and then solid foods. As discussed above, the father may want to introduce a bottle so that he can participate in feeding. Pressure to introduce artificial milk can also come from health professionals, particularly if they are concerned about the baby’s weight gain. This is often a product of outdated information and expectations, comparing breastfed babies to artificially-fed babies who have different weight gain patterns. Pressure to introduce solid foods can begin as early as 12 weeks – though at this stage often comes from older family members (since the official advice used to be to introduce solids at ‘12 weeks or 12 pounds’) who are basing it on their own experience. Pressure for solids increases as the baby gets older, with health professionals often weighing in from 16-20 weeks onwards.

Mothers may also find that as the baby gets older, if they seek support or advice for breastfeeding problems such as thrush, blocked ducts, mastitis, nipple pain, biting or teething, someone who is poorly-informed about breastfeeding may simply advise them to stop as ‘the baby is old enough now anyway’, or similar. More serious conditions such as either the mother or the baby needing surgery or antibiotics, or other drugs, often cause health professionals to advise the mother to wean a baby, though in most cases a way can be found to continue breastfeeding and have treatment.

As the baby gets older, the mother and father are more likely to feel pressure for the baby to be in a routine, and to ‘sleep through the night’. The pressure can be both internal, from their own expectations of what children ‘should’ be like, and external, with people actively telling them what the baby should be doing by now. This is often the point at which parents introduce a bottle of artificial milk at bedtime, in the hopes that the it will help the baby sleep deeper and longer. Obviously, this can interfere with the mother’s milk supply, among other things.

On the positive side, many mothers who have had breastfeeding difficulties in the early days find that things become easier once the baby is a few months old. Slightly older babies are stronger, more able to maintain a good latch, and usually develop more efficient sucking and feeding habits which means that feeds take less time and the mother has more time for other things. She may also have perfected feeding in a sling, so that she can feed and do other things. She’s likely to have gotten to grips with feeding in public by now, so taking her baby out and about with her doesn’t feel so daunting anymore. If she’s listening to her baby and following his cues, she’s probably started seeing some sort of rhythm now, which may help her to feel more confident about understanding his needs and how to mother him. Loving support from partner, friends, and family continues to be really important – especially if they can find ways to help the mother, that don’t involve feeding the baby, such as letting her get some more rest by taking him for a walk. And as ever, it is important to have access to qualified, well-informed support for any problems or questions. Such support should be easy to access, but health professionals in particular should take care to only offer support when appropriate and requested.

[i] Infant Feeding Survey 2005 http://www.ic.nhs.uk/webfiles/publications/ifs06/2005%20Infant%20Feeding%20Survey%20%28final%20version%29.pdf

[ii] The Breastfeeding Answer Book, pp 27

[iii] Ibid, pp 27 and 33

[iv] Ibid

[v] Infant Feeding Survey 2005 http://www.ic.nhs.uk/webfiles/publications/ifs06/2005%20Infant%20Feeding%20Survey%20%28final%20version%29.pdf

[vi] ibid


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