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 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.08.013
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.
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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. REFERENCES 1. American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human milk. Pediatrics 2005;115:496 –506.
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