It Is More Than “Breast Is Best”—Promoting Breastfeeding in the Modern World

My niece's first son was born at 35+5 weeks of gestation following an induction for pregnancy-induced hypertension and, although he fed well following birth, was separated from his mother for the remainder of his week-long hospital stay for close monitoring. They went home from the hospital having breastfed with a nipple shield for most of the previous day. They were instructed to visit their general practitioner (family physician), the principal primary care provider in Australia, 10 days later to check the baby's weight. My niece received no information about breastfeeding with a nipple shield or what “red flags” should prompt her to seek medical attention earlier than recommended. Once discharged, this vulnerable dyad was reliant upon the unknown breastfeeding knowledge and skills of their general practitioner.

I am sure this is not an isolated instance, either here in Australia or elsewhere. However, we know that throughout the world, many physicians have limited and patchy knowledge about breastfeeding and struggle to provide the support, advice, and care that mothers need and expect. Sometimes this is due to poor, inaccurate, or nonexistent teaching about breastfeeding and lactation during medical school or in subsequent training. Those physicians who qualified a number of years or decades ago may not see the need to update their knowledge or skills. Opportunities to receive continuing education about infant feeding may be limited or confined to those offered by infant formula manufacturers. Reading medical journals will often give a confused picture of differences in outcome between formula-fed and breastfed infants if the reader does not have the time or expertise to critically appraise the articles or consider the bigger picture with regard to infant feeding. It is therefore not surprising that, even though most physicians will tell you “breast is best,” many will not think that there are any significant differences in outcomes between infants who are breastfed or formula-fed, especially if they live in a developed country.

Consequently, even though most physicians would not recommend formula feeding, many would not openly encourage breastfeeding either, feeling that mothers should be free to make infant feeding decisions without interference by their physician. In fact, several researchers have found that a significant proportion of women is unaware of their treating physicians' infant feeding preferences.

A lack of evidence-based information is part of the explanation, but not the only one, for physicians' attitudes about infant feeding. The physician's personal (self or partner) experience of breastfeeding also affects how he or she will approach breastfeeding issues. If he or she struggled with breastfeeding and eventually switched to formula-feeding, or for some other reason decided not to breastfeed, the physician is less likely to encourage other women to breastfeed. Concern that women will feel guilty about not breastfeeding and equate not breastfeeding with being a bad mother also inhibits some physicians from recommending breastfeeding to their patients. Therefore, physicians need more than just the facts. They also need skills in presenting this information in a manner that will enable women to make informed decisions in the context of their life situation without feeling coerced or compelled. We also do women a disservice if we promote breastfeeding but do not have the resources in place so that they can easily access skilled assistance when necessary or do not provide supportive care regardless of the mother's decision.

In an ideal world, all physicians would have these skills. In the real world, although most mothers and physicians will claim “breast is best,” we have a long way to go to ensure women receive the care they deserve.