The Obstetrician as the Lynchpin to Successful Breastfeeding

B reastfeeding M edicine has been honored with the opportunity to publish the Executive Summary ¹ of the Surgeon General's Call to Action. This report was released on the morning of January 20, 2011 after many long months of anticipation and hard work. Although this represents an important plan for the nation's health, it also represents a model for other countries and communities to consider.

This report is not about “why breastfeed?” That discussion is over, as stated in the Agency for Healthcare Research and Quality report ² and by Dr. David Meyers in the First Annual Summit on Breastfeeding in 2009. ³ This report is about supporting breastfeeding, making it easier to succeed, and making a positive change in the environment for all mother–infant dyads and their success. The purpose is not to mandate breastfeeding, or imply government control over personal behaviors, but about facilitating the best for infants and mothers. This summary is just that: a summary. Please enjoy the opportunity to read this just-released Call to Action. Then consider exploring the entire report at Surgeongeneral.gov.

In addition to including the landmark Executive Summary, the centerpiece for this issue of the journal, the first for Volume 6, is the recounting of Dr. John Queenan's Founders' Lecture at the 15^th Annual Meeting of the Academy of Breastfeeding Medicine in October 2010. He gives us “An Obstetrician's View.” ⁴ But then Dr. Queenan is not just any obstetrician, he is a respected and revered giant among a cast of giants and a supporter of breastfeeding as long as we have known him. He was the representative from the American College of Obstetricians and Gynecologists in the formative days of the development of the Section on Breastfeeding at the American Academy of Pediatrics, helping to write the American Academy of Pediatrics' policy on breastfeeding. He was at the birth of the Academy of Breastfeeding Medicine. He has been lighting fires of support in the obstetrical community consistently for decades.

In this inspiring address, Dr. Queenan catalogues the many advantages of breastfeeding so important to the knowledge base of every physician. He reviews the state of breastfeeding in 2010: Where is there progress, where is there weakness or even failure to change local statistics. He points a finger at the geographic areas of failure and praises the states that are exceeding the national goals. He points out the obstacles to successful breastfeeding and highlights the opportunities for physicians to decrease or remove these obstacles.

The role of the obstetrician in promoting and supporting breastfeeding is his next target. He clearly describes the dilemma of inadequate residency curriculum compounded by inadequate textbook resources that have led to less than ideal preparation. The fact there are questions on the board exams indicates there is a move for change. Then the current state of obstetrical care, which influences mother–baby opportunities for bonding, is thoroughly reviewed from epidurals for all to early discharge. It is a grand review eloquently illustrated with tables, graphs, and illustrations. He concludes by challenging the ABM to solve some of the issues that impede the improvements in breastfeeding.

One very significant point was glossed over. The obstetrician is key to the success of every pregnancy, but not just for technical support and clinical acumen, but because of the relationship with the patient. The obstetrician is a person of trust, confidence, and knowledge. Every woman has great respect for her obstetrician and values the obstetrician's opinion and commitment. She can sense the belief that breast is best. The real attitude, however, is reflected in the entire office, the attitude of the staff, the free formula give-ways, and the accommodations for the postpartum women who are breastfeeding. The message is on the office walls.

Yes, ABM could make a difference. But ABM has only a handful of very gifted and very productive obstetricians, all of whom are laboring in the lactation vineyards. ABM needs more obstetricians. Women need the support and inspiration of their obstetrician to breastfeed. Many years ago Jelliffe and Jelliffe ⁵ wrote: “Breastfeeding is a confidence game.” This has not changed in the 40 years since it was first said. The obstetrician plays a huge role in the success of breastfeeding by instilling confidence in the patient. Thank you, Dr. Queenan, for being a leader among obstetricians.

This issue of the journal also brings forward some insight into breastmilk feeding among very low birth weight (VLBW) infants. Pineda ⁶ studied the maternal and infant factors that were associated with successful feeding of mother's milk to VLBW infants. The results demonstrate that it is the same factors in term infants that make a difference. It is the well educated of modest socioeconomic means who succeed. Poor, undereducated minorities were less likely to breastfeed at discharge of their premature infant.

The cytokine content of milk produced by mothers who delivered VLBW infants was studied by Mehta and Petrova. ⁷ The cytokine levels were robust and similar to the levels in the milk of mothers who delivered at term, which is significant for the VLBW infants who are at great risk of infection due to impairment of innate and adaptive immunity.