Which reasons for terminations are mentioned by the mothers? 

From a personal perspective, I feel there is plentiful information out there for women to make informed choices and sometimes too much pressure on women from healthcare professionals can be counterproductive. In the UK I feel this is a cultural issue and possibly increased social marketing activities need to be undertaken  to facilitate normalisation. 

I would also like to see the introduction of mandatory tongue tie checks on newborns in the UK as many new mothers I know have experienced his as an issue. Perhaps this is one reason for termination?

Holly,  thank you for this perspective, from personal/empiric observation, many women terminate breastfeeding because they lack support with proper latching on, resulting in pain.  This is the area when knowledgable health professionals can help, not so much pressure, but support.  

This matter has been a sticky wicket for decades.   Recent evidence from the Infant Feeding Practices II study indicate that feeding an infant expressed milk from the bottle is associated with obesity.  Yet women feel the economic need to return to work soon after birth.  I think the issues is partially a country and ethnic groups specific response.  Several countries other than the U.S. have maternity leave that allow for the mother to establish lactation and others do not.  The role of the health professional depends on when that person is in contact with the mother, with those who are involved in prenatal care having a wider breadth of time to address intentions to breast feed while those involved immediately postpartum are not present to address benefits as much as help in establishing lactation among those who intend to breast feed. 

There are many reasons for mothers not breast feeding. It varies between the countries, ethnic groups, income groups,education, cultural influences etc. Based on these issues , a strategy may be developed suitable for the particular communities and with regard to the reasons thereof.

The website of World Alliance for Breast Feeding Action may be helpful for further planning.

worldbreastfeedingweek.org/ ,www.waba.org.my/ , WWW.bfni.org

The first step is to LISTEN. In my research of infant feeding advice and influences on mothers' decisions in Australia last century, what I noticed was that the public health sector TOLD mothers what to do, anxious to impart the information they considered important, rather than exploring how her lived situation was relevant. Often this advice exhorted them to breastfeed, but insisting on rigid feeding schedules undermined this process.  It was interesting to see the contrast in how commercial entities approached mothers, listening to their fears in order design advertising to build on mothers' fears and aspirations - to sell foods to feed babies by  bottle. The advertisements would have given the the impression that someone was listening, that somebody cared. Both mothers and the grandmothers, who were a source of advice, were exposed to advertising

As breastfeeding is an embodied experience, mothers typically require support in the early days, at least. This is even more so in cultures such as the UK and the US, where artificial feeding has a very long history and is deeply embedded culturally.  Breastfeeding simply isn't traditionally how babies are fed in some regions.  A 2007 Cochrane Review by Britten et al found that the optimal support is a combination of professional and lay support, that is, the right support from the right person at the right time. Predictably, they found that personal support was better than telephone support. Some helpful forms of support for the breastfeeding mother can come from people who know very little about breastfeeding, but provide an encouraging word, a helpful contact, or a chair so that she can breastfeed if her baby becomes hungry while shopping.

Numerous forms of support for mothers to breastfeed are described by our chapter authors from round the world in the book I co-edited with Melissa Vickers.  Besides the better-known support groups and peer counsellors, a lovely example is the Baby Cafes in the UK and now elsewhere.  [Thorley V, Vickers MC. The 10th Step & Beyond: Mother Support for Breastfeeding (Amarillo TX: Hale Publishing, 2012).]

Holly's comments are a reminder that poor "positioning" isn't the only cause of nipple pain or infants' low weight gain, as infant oral anomalies can also be a factor. For several generations this was a neglected area for investigation and treatment, with the result that many clinicians have not learnt the skills of assessing and/or treating for tongue-tie (especially the less visible ones) and upper-lip tie, both of which can cause breastfeeding difficulties.  (If fed by bottle, these babies may slip off, gulp, dribble milk out of their mouths.)

Years ago, when breastfeeding wasn't well supported or valued, mothers and clinicians were told to ignore tongue-tie unless the child later had speech difficulties. Some parents were sad that their babies couldn't lick an ice-cream.

Rigid rules about "positioning" were an obstacle for mothers a few years ago, with the fad one "correct way". Thankfully, the focus has turn to the position that works best for that mother and that baby.

Hi.  I am a breastfeeding counselor based in Cambodia.  I'm feeling particularly vexed about this topic today.  I've just fielded a call from a dad whose partner had a CS (practically obligatory for wealthy urban women in the capital).  Even though her milk has already come in after just 2 days, the clinic staff had already put baby on formula because they “couldn't see milk”. Then they tell her that her breast is blocked when actually she’s engorged.  I recently spent almost 3 months helping a mum and baby recover time (and weight) lost when her obstetrician recommended nipple shields for no apparent reason.  In Cambodia, many urban medical professionals are creating breastfeeding problems for mothers and babies, because they have no understanding of colostrum, engorgement, or milk coming in, and also because they push birth by CS when it is not indicated.  Sorry to vent!

I want to share the analysis and recommendations on breastfeeding from the report to the President of the White House Task Force on Childhood Obesity "Solving the problems of childhood obesity in one generation"  May 2010, you can get the full report on-line.  This many be useful improving the support and education to women on breastfeeding.

The analysis: 

The protective effect of breastfeeding likely results from a combination of factors. First,infant formula contains nearly twice as much protein per serving as breast milk. This excess protein may stimulate insulin secretion in an un healthy way. Second,the biological response to breast milk differs from that of formula. When feeding a baby, the mother's milk prompts the baby's liver to release a protein that helps regulate metabolism. Feeding formula instead of breast milk increases the baby's concentra- tins of insulin in his or her blood,prolongs insulin response, and,even into childhood,is associated with unfavorable concentrations of leptin, a hormone that inhibits appetite and controls body fatness. Despite the well-known health benefits of breastfeeding and the preference of most pregnant women to breastfeed, numerous barriers make breastfeeding difficult. For first-time mothers, breastfeeding can be challenging, even for those who intend to breastfeed. For those who have less clear intent to breastfeed, cultural, social, or structural challenges can prevent breastfeeding initiation or continuation. For example, immediately after birth, many babies are unnecessarily given formula  and separated from their mothers, making it harder to start and practice breastfeeding. Also, hospital staff are often insufficiently trained in breastfeeding support. The Joint Commission on the Accreditation of Hospitals, the body that accredits hospitals and health care organizations for most State Medicaid and Medicare reimbursement, now expects hospitals to track and improve their rates of exclusive breastfeeding. Hospitals that meet specific criteria for optimal breastfeeding-related maternity care are designated as Baby Friendly by Baby-Friendly U.S.A. Currently only 3% of births in America occur in Baby-Friendly facilities.

Recommendations:

Recommendation1.3: Hospitals and health care providers should use maternity care practices that empower new mothers to breastfeed, such as the Baby-Friendly hospital standards. Hospitals and health care providers should routinely provide evidence-based maternity care that empowers parents to make informed infant feeding decisions as active participants in their care,and improves new mothers' ability to breastfeed successfully. Examples of specific practices and policies include: skin-to-skin contact between the mother and her baby; teaching mothers how to breastfeed; and early and frequent breastfeeding opportunities. Hospitals, health care providers,and health insurers should also help ensure that new mothers receive proper information and support on breastfeeding when they are released from the hospital.

Recommendation 1.4: Health care providers and insurance companies should provide information to pregnant women and new mothers on breastfeeding, including the availability of educational classes, and connect pregnant women and new mothers to breastfeeding support programs to help them make an informed infant feeding decision.

Recommendation1.5: Local health departments and community-based organizations, working with health care providers, insurance companies, and others should develop peer support programs that empower pregnant women and mothersto get the help and support they need from other mothers who have breastfed. Peer support networks should exist in all communities across the country, allowing all new mothers to easily identify and obtain help from trained breastfeeding peer counselors. Community organizations can foster the creation of peer support networks through expansion of programs like the WIC Breastfeeding Peer Counseling program. They can work with local breastfeeding coalitions to ensure existence of other peer support networks, such as La Leche League groups or Nursing Mothers Councils. They can also foster the creation of mother-to-mother support groups in community health centers and advertise these groups, particularly as part of the hospital discharge process.

Recommendation 1.6: Early childhood settings  should support breastfeeding . Child care centers and providers, health care providers, and government agencies should provide accurate information about the storage and handling of breast milk. They should also make sure child care employees   and providers know how to store, handle, and feed breast milk and understand the importance of breastfeeding.

As a IBCLC, a mother who nursed 3 children, LLL etc, CNM, FNP, DNP-s etc, this is an easy question. Have good hospital policies of rooming in, have access to Birth Centers, Early LC support, good latch, no bottle feeding attachment in the first three days of life, then a 3 day follow up return for wt check and breastfeeding check to deal with sore nipples. Honestly, this helps. Get connected to other mothers. Also you have to be motivated and having a Medela Breastpump that works, was charged to insurance at hospital discharge if possible, is also a real plus. Engorgement is hell on earth. Know this and things get better. If you don't start bottle feeding like mad from the beginning, if you know the benefits for everyone, including mom, its easier to breastfeed actually.

Janet, you've made such good points and you've stated them succinctly.  I would add that it is a good idea to teach hand-expressing so that mothers are comfortable with it for those times when they might need it.  If they want a pump or there is a particular reason for it, as you said, the operative words are "one that works" ( but not necessarily one particular brand). I've seen new pumps of supposedly reliable brands that didin't work (lack of negative pressure,, i.e. suction), as well as old pumps with inefficient seals.  Mothers blame their bodies, instead of the machine.  Unnecessary use of a pump can focus mothers' minds on millilitres, instead of infant cues, and introduce early bottle use, which wouldn't otherwise have happened. [I've covered these and related issues in my Commentary on 'The dilemma of breastmilk feeding', which I've posted on ResearchGate.]

This is a very rich and in-depth discussion on how to increase breastfeeding, support and empower women, strengthen health professionals' capacity and hospital policies for rooming-in, support and education.  When I had my children some 30 years ago, I was fortunate to be able to breastfeed them to their first birthday and then some. In the early 90's I worked at a WIC clinic and started a breastfeeding group, what an experience!  WIC no supports breastfeeding more than ever before.  The networks of women supporting each other is amazing.  Now as I support my daughter-in-law breastfeeding, I have learned so much more! She now has the many more useful tools like Medela Breastpump which very useful,  she also has the Lansihoh therapearl 3 in 1 Breast therapy which has been invaluable with engorging and helping with let down!  The special pillow for breastfeeding and so many other useful things that are now available to help women breastfeed.  Thank you to everyone who has contributed and shared their valuable knowledge and experience.  Still only 3% of hospitals have the rooming in and lactation consultants available.  There is yet much to be done and all the advocacy and promotion is critical to support more women breastfeeding, for their health and the baby's.  

You are so right, Maria, that hospitals need to give that critical early support. When they do, it is wonderful to see.  When they don't, they fail mothers and it takes longer to help fix what has gone wrong.  Only 3% rooming in is surprisingly low.  Here in Queensland, it would be very unusual not to have it, as rooming in has become part of the culture.  Your work with helping mothers through WIC has, I'm sure, given them the support they couldn't find till they met you. Groups where they can share experiences and learn from each other, as well as the facilitator, are very powerful in providing the necessary support. Now you are supporting your daughter-in-law.

Pillows suit some women, and can work well with very small babies, but not with others. They can also assist a mother with a deformed or partly paralysed arm, to make it easier and safer to hold her baby and breastfeed.  However, women with larger breasts can create nipple pain if they use a pillow, because the pillow places the baby too high - above where their nipples naturally are.  With a pillow, the mother then has to raise her heavy breast and keep holding it at the same level as the baby's mouth. When her hand is tired or she relaxes her hold, the weight of the breast pulls on the nipple and messes up the latch. Ouch! Taking the pillow away may work for some - or using a more laid back feeding posture.

There are so many variation in body type, and what I love about helping mothers and their babies is helping them get breastfeeding right for this mother and this baby. Like you, I also love that we are all learning, all the time. None of us 'knows it all'!

I also think that you are right Maria. Fifteen years ago I was the Deputy medical Officer of the National Food and Nutrition Service in my country, Senegal. We use to organize many sensitization activities for mothers at community level. Thèses sensitizations activities were focused on how to improve breastfeeding. We  taught to the concerned mothers how to do it taking into account the cultural aspect of breasfeeding which is really important otherwise they won't take into account the advise. For the semi urban and urban areas the most difficult thing was how to convice working mothers to express their milk and continue exclusive breastfeeding. It's a long way to go but we were able to increase exclusive breastfeeding . Till now I try to include nutrition community practice including breasfeeding in the Bank programmes in sub saharan countries.

Maïmouna Diop Ly

Physician, specialized  in Public health  and nutrition

Hi Maimouna,

The work you are doing with mothers in sub-Saharan countries is important. I love it that you are taking into account the importance of culture. That's so important for making a connection with mothers. I agree with you that mothers don't see advice as useful unless it is presented within the context of the culture - and that also means sub-cultures within the culture.

In the past there has been too much "telling" and not listening, too much advice from people from outside the culture. Mothers, like everyone else, feel they "own" the information if it is presented in a way they see can fit into their lives.

Virginia Thorley

Cultural Historian of the History of Medicine

(as well as International Board Certified Lactation Consultant)

This is an important topic. We often talk but offer no practical solution. As a culture here mothers sleep with their babies and we encourage them to do so. I remember a mother who had a baby with clef lip & palate telling me that she had not bought a cot for her baby -would it be safe for her to sleep with her baby? My answer was yes. Of note my hospital has no baby cots in the postnatal wards. Some of you might be alarmed with this but we note that sudden infant death is uncommon in our environment. Follow up after discharge from hospital is an area which we may need to emphasize which can be done in encouragement of support groups. I was fortunate to have one when I had my children as we supported and learned from each other. A lot of women especially in the urban setting are becoming more isolated and some get information from the internet - some of which is inappropriate. Teaching mothers to hand express their milk is very  handy is it can easily be done quietly and anywhere

Dear Rachel ,

I totally agree with your statement. In Senegal we do not have cot in the ward and it was  done on purpose to enhance exclusif breastfeeding. It is also part of the UNICEF Directives Baby Friendly Hospital strategy. As a medical Doctor specilaized in nutrition I used to sleep with my baby and it was fantastic. But as you said there is a need for support.

Maïmouna

Dear Rachel,

Firstly, the healthy professionals should be married and have children because of  they  add  their experiences to information.

Then, the Midwives encourage mothers during pregnancy and normal delivery immediately and the best way to promote it is skin to skin contact.

Finally, the health professionals practice should assessment repeatedly by mothers and high and medium levels principals.

Thanks for the comments. But we should not penalise health professionals without children because even them can do the job as well. Of course personal experience can be both ways those who succeeded and those who did not

From my own observation some  of these health care professional do not exclusively breast feed their infants and some of these mothers make reference to the health care professional particularly the female health care professional i think in my own opinion , they should practice what they preach