Download COMMENTARY Provider Encouragement of Breastfeeding: Efficacy

COMMENTARY
Provider Encouragement of Breastfeeding: Efficacy
and Ethics
Donna J. Miracle, RNC, CLE, PhD, and Valita Fredland, JD, MA
The health and economic benefits of breastfeeding are
well documented, and mothers’ milk is considered the
optimal feeding method for almost all infants.1– 4 Reports
of benefits for breastfed infants and children include
decreases in otitis media,5–7 atopic dermatitis,8 and
gastroenteritis,9 –11 as well as a lower risk of obesity12,13
and asthma.14 –17 Additional benefits include a reduced
incidence of sudden infant death syndrome,18,19 type 1
and type 2 diabetes mellitus,20 –23 and childhood leukemia.24,25 In addition, there are maternal health benefits of
breastfeeding that include reduction in the risk of breast
cancer,26,27 ovarian cancer,28 –31 type 2 diabetes mellitus,32 and an association between not breastfeeding and
postpartum depression.33–35
Given this evidence, health care providers should take
an assertive stance in promoting, protecting, and recommending breastfeeding to expectant and new mothers.
This is consistent with current professional policy statements1– 4 on breastfeeding and the use of human milk.
This commentary discusses the ethical obligation for
provider encouragement of breastfeeding, given the state
of the science regarding the health benefits of breastfeeding.
MOTHERS’ NEEDS FOR INFORMATION
Mothers often present to the clinical setting without
enough information to make an informed decision about
infant feeding. They often lack knowledge about the
differences between feeding methods or how to go about
learning the skill of breastfeeding,36 and look to health
care providers for this information.37,38 Studies36,39 report that women who chose formula feeding knew that
human milk was “best” but felt that formula was “adequate.” In one study of mothers of preterm infants,36 the
participants reported not knowing that there was a
difference between formula and breast milk and appreciated being given this information. Because health care
providers offered evidence about these differences, all
participants in this study changed their initial decision
Address correspondence to Donna J. Miracle, RNC, CLE, PhD, 6820
Parkdale Place, Ste 109, Indianapolis, IN 46254. E-mail: dmiracle@
clarian.org
Journal of Midwifery & Women’s Health • www.jmwh.org
© 2007 by the American College of Nurse-Midwives
Issued by Elsevier Inc.
from formula feeding and provided their own milk to
their infants for a minimum period of 30 days after birth.
Mothers also expressed the opinion that health care
providers who told them that breast milk and formula
were the same had failed to do their job. This study
illustrates how mothers depend on health care providers
for knowledge and information about the differences
between human milk and formula feedings, and the
relationship of infant feeding method to health outcomes.
FACTORS THAT AFFECT THE MATERNAL DECISION
TO BREASTFEED
Studies of maternal choice about infant feeding methods40 –52 consistently find that mothers who elect to breastfeed are, on average, older, have more years of formal
education, and report higher household incomes than
women who formula feed. In addition, these women tend
to have social support, such as mothers, family, and/or
friends, and live with the baby’s father.
Women choose their feeding method based on perceived
benefits to themselves and/or their infants. In addition,
mothers report choosing to breastfeed for consistency with
traditional values,41 convenience,49,51 and self-efficacy.45,48
Other studies have documented mothers’ awareness that
human milk confers unique infant health benefits and for
many women, this is the most important rationale for
choosing to breastfeed.36,41,42 Mothers are influenced to
choose breast or formula-feeding based on the preferences of others such as fathers,45– 47 mothers, relatives,
friends,45– 49 and health care providers.36,37,42– 44
A large national survey found that provider encouragement exerted an independent positive influence on
breastfeeding initiation across all strata of the sample.50
This study found that women who were encouraged by
health care providers to breastfeed were more than four
times as likely to initiate breastfeeding than women who
did not receive this encouragement. More importantly,
provider encouragement significantly increased breastfeeding initiation by more than threefold among lowincome, young, and less educated women, by nearly
fivefold among black women, and nearly elevenfold
among single women.50
A recent Cochrane review37 of support for breastfeed545
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ing evaluated 34 randomized trials that included 29,385
women. The analysis found that women who were
encouraged by health care providers to breastfeed were
less likely to stop breastfeeding at 4 months after birth
(16 trials, relative risk [RR], 0.94, 95% confidence
interval [CI], 0.87–1.01), and more likely to breastfeed
exclusively in the first 3 months after birth (RR, 0.91,
95% CI, 0.84 – 0.98).
Because health care providers can and do influence
their patients’ decisions about the choice of infant feeding, it is important to consider how to translate the
evidence into a message health care providers can deliver. It is important that health care providers, individually and collectively, make a comprehensive, strategic
plan to protect, support, and recommend breastfeeding.
This plan should be in place from the initial patient
contact and throughout the prenatal course. Then, a
collaborative approach with the hospital system would
ensure follow through with education and breastfeeding
management.
ETHICS OF HEALTH CARE PROVIDERS: WHAT IS THE ROLE
AND RESPONSIBILITY?
Based on scientific evidence that human milk confers
unique health benefits to both the mother and the infant,
health care providers caring for an expectant or new
mother and her infant have an ethical obligation to
discuss all appropriate and applicable issues related to
breastfeeding. First and foremost, a mother is not able
to exercise her right to autonomy and a self-determined
decision about breastfeeding for herself and her infant if
her health care provider does not ensure that she has the
relevant information. Informed consent is a “shared
medical decision-making . . . process in which the provider shares with the patient all relevant risk and benefit
information on all treatment alternatives and the patient
shares with the provider all relevant personal information
that might make one treatment or side effect more or less
tolerable than others.”53 To meet the obligation of shared
medical decision-making, health care providers must
provide scientific evidence known about the risks and
benefits of breastfeeding as well as alternative infant
feeding methods.
Health care providers must carefully consider the
content of their informed consent discussion with women
who are in a position to consider breastfeeding. Honesty
and respect are fundamental to any exchange between
two people. In the context of breastfeeding, they bear
greater weight because of the different power positions of
Donna J. Miracle, RNC, CLE, PhD, is in clinical practice at Indiana
Mothers’ Milk Bank, Inc., Indianapolis, IN and a faculty member at
Indiana Wesleyan University.
Valita Fredland, JD, MA, is an attorney in the legal services department at
Clarian Health Partners, Inc., Indianapolis, IN.
546
the health care provider and the patient. Health care
providers should consider and disclose any relationship
with entities that could unduly influence their recommendations for or discussions about feeding methods with
new and expectant mothers. The most obvious conflict of
interest would involve a health care provider who receives money from any industry with a conflicting
interest in regard to breastfeeding promotion. Health care
providers should also consider their involvement in research, commerce, and/or politics that may influence their
ability to share honest and accurate information about
breast or formula feeding.39,53
Health care providers are also obligated to disclose
evidence of potential harm related to infant feeding
method when counseling mothers about the risks and
benefits of all feeding options for infants. Clinicians offer
evidence-based counseling about the risks of tobacco use
and not using car seats, seat belts, or other preventive
health measures, they should take a similar stand when
discussing breastfeeding. Breastfeeding information should
be presented as a preventive health strategy. This is
especially important for vulnerable populations who are
statistically less likely to breastfeed and who are most
influenced by health care providers.
CONCLUSION
Health care providers can and do influence women’s
decisions about the choice of infant feeding. They have
an ethical obligation to provide adequate information
about the benefits of breastfeeding and the potential
harms associated with not breastfeeding so that mothers
can make an informed decision. Therefore, providers
need to consider how to translate the evidence into a
message that is easily and consistently delivered. Health
care providers should work collaboratively to develop a
comprehensive, strategic plan to protect, support, and
recommend breastfeeding. This plan should be in place
from the initial patient contact and throughout the prenatal course. Then, a collaborative approach with the
hospital system would ensure follow through with education and breastfeeding management.
To optimize infant and maternal health outcomes
through human milk feedings, it is imperative that all
health care providers working with new mothers be
knowledgeable about human milk feedings and breastfeeding management, it should not be left to a unique
group of professionals. Midwives and women’s health
professionals should be competent to provide assistance
with the breastfeeding fundamentals, such as latch and
positioning, as well as assistance with common breastfeeding and lactation problems ranging from sore nipples
to delayed lactogenesis. All office and hospital personnel
should have training on what exemplifies a breastfeeding
friendly environment. Art work and patient literature
should be reviewed to ensure that content and messages
Volume 52, No. 6, November/December 2007
portray breastfeeding as the optimal feeding method, in a
positive, culturally appropriate manner. To provide breastfeeding friendly care means to continually evaluate and
raise awareness about the environment so that mothers
feel comfortable and accepted when breastfeeding
throughout waiting room and office spaces. In addition,
hospital practices should promote and support the unique
needs of breastfeeding mothers and infants from an
evidence-based perspective.
Finally, evidence-based breastfeeding practice means
that health care providers are aware of current professional policy statements related to breastfeeding and
incorporate these recommendations into the clinical setting. It is through access and dissemination of knowledge
from health care providers that mothers are then empowered to make a fully informed decision about a feeding
method.
A strategic plan such as described above promotes
patient advocacy, conforms to ethical principles, and
emphasizes the responsibility for all health care providers to actively recommend and promote breastfeeding to
expectant and new mothers. Implementing evidencebased provider encouragement of breastfeeding is essential in the current health care environment that emphasizes clinical excellence, improved quality of patient
care, informed decision making, and optimal patient
outcomes.
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