A good start to nursing is foundational and we have examined how some factors in the first days impact breastfeeding. However, there are numerous other factors which come into play after the first few days which also have an effect on breastfeeding duration.
Intended DurationOne of the most significant factors on the duration of breastfeeding is the length of time the mother intends to nurse. 1, 2 In most cultures, there is a social norm regarding how long most infants nurse. Interestingly, in our culture, which is largely unsupportive of breastfeeding, such a social norm does not exist. The majority of new mothers do initiate breastfeeding in the first few days after birth, but most terminate nursing in the first eight to twelve weeks. This reflects the fact that our society recognizes the value of breastfeeding scientifically, yet is non-committal to it.
So how long should a mother expect to nurse her baby? The American Academy of Pediatrics recommends only human milk for the first six months. 3 Others advise twelve months of breastfeeding, since cow’s milk is not advised until the first birthday, and pediatricians recommend formula if human milk is discontinued before then. This recommendation to nurse for twelve months is based on the recognition that, not only are breastfed infants healthier, but formula-fed infants are often sicker. Therefore some recommend at least 12 months of breastfeeding until cow’s milk can be consumed.
Others take the pragmatic position of allowing the child to initiate weaning. Mothers who have successfully nursed will often talk about the fact that their child indicated when they were done nursing. Some infants have indicated a readiness to wean as early as six months, while others have continued to nurse for two years or more.
It is beneficial for the expectant mother to consider how long she intends to nurse. Mothers who intend to nurse for a specific period are usually more motivated to work past the problems that may surface due to the breastfeeding hindrances that most babies are exposed to in the hospital. If the mother has not intended to nurse for any particular duration, it is more likely that she will give up if such problems do arise.
Maternal Confidence, Support, Emotional StateAnother important factor that increases the duration of breastfeeding is maternal confidence.1,2,4 It makes sense that the more confident the mother is, the greater the likelihood of her continuing to nurse. What may be a little harder to directly measure, is what increases or decreases her confidence.
It is logical to expect that emotional support, a social network of mothers who have successfully breastfed, and a basic education regarding breastfeeding would enhance confidence.
Maternal depression also has a negative effect on duration.5 Clinical depression has a motivation-reducing impact; and breastfeeding may take more motivation than a woman suffering from depression may have. This can produce a negative feedback loop for the depressive symptoms: the depression causes termination of breastfeeding, which increases lack of confidence, and increases depression. Dealing with depression will be discussed later.
Breastfeeding EducationOne study indicated that the single most important hospital factor to influence breastfeeding duration was education.6 In the study, the education was antenatal classes. Again, it is probably that the educational experience increased maternal confidence; while simultaneously it is possible that women willing to attend a class are more likely to be self-motivated and perhaps have more social support encouraging them to attend. Thus the factors of motivation, education, support and confidence are likely intertwined.
If a mother is lacking in any of these four areas (motivation, education, social support, personal confidence) education is the most concrete assistance to provide to her. It is logical to anticipate that pursuing breastfeeding education will also strengthen the other three areas as well.
Education regarding breastfeeding should not be confined to antenatal classes and literature given at the time of birth. These are valuable, but it may be anticipated that postnatal education may further increase breastfeeding duration. Considering the amount of information a family is taking in through childbirth classes, antenatal breastfeeding classes, and at the time of hospitalization, it is highly probable that a significant amount of that information has not been internalized.
As a matter of course, women should contemplate increasing their breastfeeding knowledge through education at four to six weeks postpartum. When a mother is four weeks postpartum, and the scenarios of her pregnancy and birth are receding, breastfeeding education can confirm what she has learned and give her new strategies as well.
This postpartum education can come from support groups such as La Leche, from videos, or from books. The availability of peer counselor support and breastfeeding videos has been shown to increase duration among minorities that typically have a lower rate of breastfeeding.7
Provider SupportAnother significant factor influencing breastfeeding success is the support of health care providers. 1, 8, 9, 10 Health care professionals can support breastfeeding by encouraging expectant mothers to breastfeed, avoiding distribution of formula samples and literature, and providing support and education if a woman encounters difficulties. The behavior of healthcare professionals that is highly indicative of breastfeeding termination is advising the mother to add supplemental formula. The addition of supplemental formula itself decreases the duration of time the infant nurses, as well as decreasing the quantity of human milk received prior to termination. In addition, the advice to supplement usually decreases confidence, which has already been shown to be an important factor in the length of nursing. It also indicates to the mother that nursing is not important, otherwise health care workers would support it.
Interestingly, in our society that has a medical specialist for virtually every organ and every disease, there are no breastfeeding specialty programs within the physician community, and instruction on the lactation process is not covered in medical school. Obstetricians consider infant feeding the domain of pediatricians. Pediatricians consider female breasts the domain of obstetricians. Family practitioners are likely to support or not support breastfeeding based on their personal, family experience. In other words, those that nursed their young support nursing. If they chose not to, they do not support it.
A breastfeeding friendly family nurse practitioner discussed one typical encounter with a pediatrician. While doing a pediatric orientation, she met a young nursing mother who was experiencing problems. As she began counseling the mother regarding the issue, the pediatrician told her she was not allowed to discuss it in that practice. She then proceeded to refer the mother to the hospital lactation consultants, but was told that it was not a pediatric issue and she was not allowed to give that recommendation. What is most disheartening about this incident was not that the physician would not support breastfeeding, as that is altogether too typical. But in this case, a pediatric practice that was considered amongst the most supportive of breastfeeding in the area, refused to allow a nurse practitioner, who had undertaken additional lactation education, from providing the most simple information to a vulnerable family.
“Just supplement with formula,” is all clinicians have time to say. Lack of clinical time has been identified as a barrier to support of breastfeeding.7 “It’s not my issue, it’s someone else’s,” becomes a convenient excuse.
Mothers can increase their breastfeeding success by finding caregivers who support nursing. If they are advised to supplement, they are more apt to continue breastfeeding if they contact a lactation consultant or other breastfeeding advocate who can assist them with any problems, and possibly refer them to a physician who is breastfeeding friendly.
Exclusive BreastfeedingExclusive breastfeeding also impacts the duration.2, 7 Formula decreases the amount of breast milk made by more than the amount of formula consumed. If an infant drinks 4 oz of formula, the mother will probably produce 5 or 6 oz less milk. The corollary to the principle “The more you nurse, the more milk you make” is “The more you supplement, the less you make.” This puts the breastfeeding process into the negative cycle.
Maternal-Infant ProximityIf the mother returns to work or school, the duration of breastfeeding is often reduced. It is understood that the economic environment today makes it more difficult for women to stay home with their infants. A few decades ago the career-minded professional woman was more likely to return to work than her blue collar counterpart. Today, that trend has been reversed, and it is often the professional woman that may have the means to stay home, while families with less education and lower incomes have a decreased ability to exercise that option. One mother who had a low paying job at a grocery store to make ends meet remarked about the irony of having to pay so much for expensive formula because she needed the money for food, but could not stay home and nurse her baby for free. This is a difficult situation with no easy answers. Some have found creative solutions by finding flexible employers who have baby-friendly policies, job sharing, or working at home. Flexible options do exist, though they may not be available to all women.
Finally, sleeping arrangements impact breastfeeding duration. A woman is more apt to continue breastfeeding if the infant is physically near her. The simpler the breastfeeding arrangement is for nighttime feedings, the longer those feedings will continue. Families can look for safe, proximal sleeping arrangements. That means the infant is close at hand, but actually lying on a surface that is made to be baby-safe. That may include having the crib next to the bed, using a co-sleeper (which attaches to the bed), using a basinet, or ensuring that the parent bed is made infant-safe.
Breastfeeding does take commitment. Our society in particular places little value on the mother/infant relationship, ignores the wholesomeness and superior value of breast milk, and considers institutional practices that are proven to hinder the breastfeeding process as normal. It is no wonder that so many quit. How many sleep-deprived mothers with a howling, hungry three week old who has not been able to obtain an adequate milk supply from her cracked and sore nipples cries, “Is it worth it?”
Those mothers who avoided early problems; or who triumphed over them, can answer in the affirmative. Optimal nutrition and infant health are worth it. Just as important, the Mother/Baby Rhythm that allows infants to grow and develop and mothers to don the role of motherhood effectively, is initiated and maintained by breastfeeding.
References1 Blyth, Creedy, Dennis. Breastfeeding duration in an Australian population: the influence of modifiable antenatal factors 2004
2 Chezem, Friesen, Boettcher. Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices. 2003
3 American Academy of Pediatrics Breastfeeding and the use of human milk. 2005
4 Taveras, Capra, Braveman, et al Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. 2003
5 Dennis, Janssen, Singer. Identifying women at-risk for postpartum depression in the immediate postpartum period. 2004
6 Guise, Palda, Westhoff et al. The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Prevention Services Task Force. 2003
7 Gross, Caulfield, Bentley et al. Counseling and motivational videotapes increase duration of breast-feeding in African-American WIC participants who initiate breast-feeding. 1998
8 Taveras, Li, Grummer-Strawn et al Opinions and practices of clinicians associated with continuation of exclusive breastfeeding 2004
9 Lu, Lange, Sluser et al. Provider encouragement of breast-feeding: evidence from a national survey. 2001
10 Wolf. Low breastfeeding rates and public health in the United States. 2003
By Karen Newell Copyright 2003 - 2012 Better Childbirth Outcomes - All Rights Reserved
Camp Hill, Pennsylvania, USA