The role that health care providers can and should play in promoting breastfeeding has come under scrutiny in recent years, often leaving doctors uncertain about how to discuss infant-feeding intentions with patients.
There’s been a backlash against the public health promotion of breastfeeding and “lactivism,” with critics saying that the efforts lead to shame or guilt in women who do not breastfeed. And often mothers, and their physicians, have been caught in the crossfire.
The American College of Obstetricians and Gynecologists attempted to build a bridge across this divide in their updated Committee Opinion on breastfeeding in February.
In a departure from the language typically included in policy statements or clinical guidelines from other medical organizations, the new ACOG guidelines urged ob.gyns. and other obstetric care providers to “support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant.”
At the same time, however, the organization also “recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced through the infant’s first year of life, or longer as mutually desired by the woman and her infant.”
Striking the right balance in providing women with adequate information to make informed choices without inadvertently causing a woman discomfort requires clinicians to start by finding out what their patients already know, according to Dr. Alison Stuebe, lead author of the ACOG opinion and an assistant professor of maternal-fetal medicine at the University of North Carolina at Chapel Hill.
“The clinician’s role is to help that mom make an informed decision, and it’s hard to help her do that if you don’t know where she’s coming from,” Dr. Stuebe said. “It’s important not to assume that a woman knows everything or knows nothing.”
How to start the conversation
Dr. Stuebe, who is also a distinguished scholar of infant and young child feeding in the Gillings School of Global Public Health at UNC, recommended bringing up the subject of breastfeeding early in a woman’s prenatal care with a simple open-ended question: “What have you heard about breastfeeding?” The answer helps tailor the counseling to the mother’s knowledge, feelings, and attitudes.
“We have some moms who have read 47 books on breastfeeding, and then there are women who live in a family where they’ve only seen bottle feeding,” Dr. Stuebe said.
Next, validate what the mother says, and ask for more information from the mom. When the conversation begins early in the physician-patient relationship, there is time to have the conversation over several visits, Dr. Stuebe said.
“I think asking the question in a nonjudgmental, truly open-ended way and listening to what mom says and paraphrasing it back to her hopefully helps her feel comfortable enough to go into a bit more detail,” she said. “I don’t ask people to commit. I take notes and we talk about it at another visit.”
Dr. Stuebe also suggested making sure mothers are aware of the benefits of breastfeeding for their own health – such as a reduced risk of type 2 diabetes and breast cancer – so that the conversation is not framed entirely in terms of benefits for their child.
Fear of upsetting a patient, however, should not dissuade physicians from broaching the subject, she added. “In the fear of making moms feel bad, we sometimes tiptoe and miss an opportunity to provide moms with an opportunity to make an informed choice.”
That would be especially unfortunate given the respect individuals continue to have for advice from their physicians, said Lora Ebert Wallace, Ph.D. , professor of sociology at Western Illinois University in Macomb, who has studied the impact of language used in breastfeeding discourse.
“Medical authority is a real thing,” Dr. Wallace said. “People listen to their doctors and respect them, and doctors want to be really thoughtful about how to communicate, starting with questions instead of prescriptions.”
Avoiding ‘risk’ language
In reality, much of the backlash against breastfeeding prescriptivism has not involved the ob.gyn. community, Dr. Wallace noted.
“I think generally ob.gyns. have not been on the forefront of the type of advocacy that people have objected to,” she said. “I think that’s come from other areas of medicine.”
Some of that advocacy has employed “risk language,” in which breastfeeding is presented as the only appropriate choice and the conversation centers around the “risk” of formula feeding instead of the “benefits” of breastfeeding.
“Our research suggests that the use of risk language is premature at this point because it has not been well evaluated, and the evaluations that have been done suggest that it doesn’t increase breastfeeding among people exposed to it,” Dr. Wallace said. “There is some suggestion from qualitative research that you can create a backlash to the information.”
The thinking behind risk language is that using stronger language to encourage breastfeeding will somehow make more women choose to do it, but such a rationale ignores the fact that parents are already trying to do the absolute best they can for their children, Dr. Wallace said.
“I don’t think the research supports the idea that women aren’t breastfeeding because they don’t know it’s good for their babies,” she said. “They’re not breastfeeding because it’s hard because of the way we structure our society and our workplaces.”
Another statement to avoid is “every woman can breastfeed,” said Laura Lallande , the lactation services coordinator at Oregon Health and Science University, Portland.
“There are real, legitimate physical reasons some women cannot or choose not to breastfeed, and we need to stop propagating the myth that formula feeding is equivalent to moral failure,” Ms. Lallande said. “As with anything in health care, our job is to meet clients where they are, not where we want them to be. If we start from a point of judgment, we block progress before it starts.”
Potential sources of shame
It is the “everyone can if you try hard enough” language that can lead to shame, Dr. Stuebe said.
The feelings of shame some women may feel if they don’t breastfeed can arise from the inappropriate conflation of breastfeeding and being a good mother. “Particularly for first-time mothers, the transition from what I want to be as a parent to what I can be as a parent is wrenching for some women,” Dr. Stuebe said.
The social infrastructure in the United States means that breastfeeding is not actually a “choice” for all women, Dr. Stuebe said. This reality is reflected in the ACOG statement , which encourages ob.gyns. to “be in the forefront of policy efforts to enable women to breastfeed, whether through individual patient education, change in hospital practices, community efforts, or supportive legislation” and to promote policies that accommodate milk expression, such as paid maternity leave, on-site child care, break time, and a location other than a bathroom for expressing milk.
Even the way the health care system is set up makes it hard for mothers to get holistic care, Dr. Stuebe said.
“What happens is moms get conflicting advice from [their] provider and the baby’s provider, and sometimes even from a third source such as a lactation consultant, and they’re left trying to triangulate that information,” Dr. Stuebe said. “Nobody is saying, ‘How is this whole mother doing and how can we meet her needs?’ ”
That’s why it’s important to follow up with patients and ask how breastfeeding is going, Dr. Stuebe explained. If it’s not working out, women need to know it’s okay to stop.
“Breast milk is important, but a woman’s well-being is also important and if everything about breastfeeding is awful, that’s not helping her or her baby,” Dr. Stuebe said.
Physicians have a responsibility to tell women that breastfeeding is advantageous, Dr. Wallace said, but they also have a responsibility to listen to patients and be sensitive to what they’re hearing.
“To the parent in the moment, if they’re facing something really important about employment or housing, the breastfeeding decision may not look as important to them,” Dr. Wallace said.
Yet ob.gyns. should never discount how critical their role is in helping mothers successfully breastfeed if they choose to, Ms. Lallande said.
“Even when things are great, breastfeeding is physically and emotionally challenging,” Ms. Lallande said. “Women need support from providers who listen to them and help them navigate the sleep-deprived early weeks of motherhood. Especially with first-time moms, the relationship with the OB is much stronger than the relationship with the pediatrician, so they call the OB for help.”
