Take my milk for gall

Come to my woman’s breasts and take my milk for gall. Even Lady Macbeth was not without an opinion on the uses of a woman’s breast… And so it continues to this day; almost everybody has an opinion on breast feeding. This runs the full gamut from the harangue of Elisabeth Badinter in her March 2012 article in Harper’s Magazine: The Tyranny of Breast Feeding to the quasi-religious sermons published by the La Leche League that engender parent-like guilt for even considering alternatives.

It is, as they say, a Motherhood Issue: something valued in principle, honored for its obvious benefit to baby, and yet often abandoned in the frustrating weeks and months after birth when the glow has faded along with sleep and patience. There are data from various national surveys which show that on average although around 90% of Canadian mothers start out with good intentions and exclusively breast feed their baby -i.e. offering only breast milk (plus or minus vitamins, medicines, etc.) and no supplementation with other liquids, (formula, juices, etc.)- less than 25% continue with it. The World Health Organization recommends exclusive breast feeding each infant for the first six months of its life. Yes, the benefits to baby are that important!

Interesting though, despite the obvious benefits, there are various impediments to the practice: Culture -or is it country and its customs?- for one. The WHO has a global data bank on breastfeeding and some of the figures reveal startling differences by country alone -and not all related to social disparities in health, education or economics.

But admittedly, there are Canadian studies that suggest that breast feeding is chosen less often among single mothers, women with less education, or lower incomes. Some may not even choose to start breast feeding, let alone abandon it early. And when it is chosen, almost 50% of the ones who choose not to continue, stop within the first six weeks… So given this finding, is there anything that might help support, or lend itself to intervention in that critical window of time?

There is an article in the Canadian Medical Association Open Access Journal in January of this year (cmajo january 16 2013 vol.1 no. 1 E9-E17) that looked at just that, in 2 regions in the province of Nova Scotia between 2006 and 2009. Their exclusive and dropout breastfeeding figures were different from the Canadian average, but even so, they did identify “four potentially modifiable risk factors: prepregnancy obesity, smoking during pregnancy, no intention to breast feed, and no early breast contact by the infant.”

It’s that latter factor -the “no early breast contact by the infant” (read skin-to-skin contact, I would imagine) that intrigues me, though: that such a simple thing -placing the baby on the mother’s skin near her breast after delivery- could create so much difference! This is a policy I would have thought would be universal by now: we even encourage it after extraction of the baby during a Caesarian section in our hospital if the baby is healthy. Its what almost every woman craves -and baby as well- so why not?

And yes, the other modifiable risk factors loom large as potential targets -especially the ‘no intention to breast feed’ decision. One wonders whether frequently bringing up the topic in a respectful and sensitive manner as the pregnancy progresses (and her trust and bond with the health-care provider increases) might be helpful.

The other interesting thing I learned from the paper was that “educational interventions are more effective if focused on improving maternal self-efficacy than on enhancing knowledge.” Most women nowadays know why they should breast feed; it’s how to breast feed, especially with difficult infants and problems latching once they’ve left the hospital, that frustrates them and causes them to stop trying after a few weeks -or even days… Small communities seem particularly at increased risk, often because of a scarcity of easily accessible resources. Recognizing that continued support is very important in the early days after delivery is obviously an important key. So postpartum enthusiasm for breastfeeding on the part of the nurses and staff before the woman even leaves the hospital is the first step. Ideally, a 24 hour breast feeding hot line (perhaps utilizing the existing hospital maternity ward) would be helpful -night time is when the woman is tired and irritable and more prone to frustration. Lactation consultants -maybe also recruited from maternity nurses in the local hospital- would be another important resource. Of course, a knowledgeable and empathetic family doctor or midwife -and an understanding and patient partner- complete the readily accessible communal facilities… Support and understanding are what a community can supply with very little extra resources: the ounce of prevention strategy, I suppose.

But preemptive encouragement is even cheaper; so is motivation -prenatal motivation especially. It doesn’t take much time for the doctor or midwife to inquire about it, and often merely the willingness to listen to her concerns about breast feeding -or her doubts about her abilities- is enough to get the woman thinking.

No… I suspect that breast feeding is not for every new mother… but who knows, maybe it could be.

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