Infant feeding practice in mothers at risk of low birth weight delivery

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Midwifery

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Infant feeding practice in mothers at risk of low birth weight delivery Lynda Rajan and Ann Oakley

D a t a relating to infant feeding practices w e r e o b t a i n e d b y a 6 w e e k p o s t n a t a l q u e s t i o n n a i r e f r o m 459 w o m e n w h o p a r t i c i p a t e d in a r a n d o m i s e d controlled trial of social s u p p o r t in p r e g n a n c y . T h e y r e p r e s e n t e d a 9 0 % response r a t e f r o m 507 w o m e n with a past history of a low b i r t h weight b a b y before the index p r e g n a n c y . T h i r t y - n i n e p e r cent of the babies weighing m o r e t h a n 2500 g w e r e b r e a s t fed completely. W o m e n w h o e x p e r i e n c e d a d e l a y of m o r e t h a n h a l f a n h o u r b e t w e e n b i r t h a n d first suckling, a n d those w h o were given p e t h i d i n e d u r i n g l a b o u r b r e a s t fed for a shorter period, as did those w h o g a v e c o m p l e m e n t a r y bottle feeds. By considering the w o m e n ' s reasons for discontinuing or not initiating breast feeding, this p a p e r suggests t h a t i m p r o v e d social s u p p o r t f r o m h e a l t h professionals a n d others in the p o s t n a t a l period c a n increase b r e a s t feeding success rates.

INTRODUCTION This paper reports part of the data from the Social Support and Pregnancy Outcome (SSPO) Study. The study was a randomised controlled trial testing the hypothesis that social support during pregnancy to women at above average risk of low birth weight (LBW) delivery could increase mean birth weight and improve a range of maternal and infant health outcomes. Some of the descriptive data collected in the course of the study encompass the experiences, attitudes and beliefs about infant feeding of women in this sample of women with a history of LBW delivery. The study participants were living predominantly in socially disadvantaged circumstances. This paper reports on the feeding Lynda Rajan BA(Hons), MSc, Project Co-ordinator. Ann Oakley MA, PhD, Deputy Director, Thomas Coram Research Unit, University of London Institute of Education,41 Brunswick Square, London WC1N 1AZ. (Requests for offprints to LR) Manuscript accepted 10 November 1989

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intentions, experiences and practices in a population of women at above average obstetric and social risk. It should be remembered that our sample is not representative of the population as a whole. However, we are presenting data on feeding practices in a group of women who have for many years been identified in policy and research documents concerned with infant feeding as a critical group.

METHODS The SSPO study was a randomised controlled trial (RCT) of non-directive social support intervention in pregnancy. Five hundred and nine women with a history of LBW delivery were recruited at 'booking' from four obstetric units in England (two in the Midlands and two in the South) between J a n u a r y 1986 and M a y 1987. O f these, 255 were randomised to social support intervention in addition to standard antenatal care and 254 control women received standard

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antenatal care only. Allocation to intervention or control group was on the basis of a table of random numbers. The social support intervention, which started early in the second trimester, consisted of the offer of a minimum package of three home visits and two telephone calls (or brief home visits for women without a telephone) from a research midwife, plus a 24 hour a day contact phone number so women were able to get in touch with 'their' midwife whenever they wanted. The research midwives did not provide health education or clinical care, but attempted to respond in a sympathetic way to whatever questions and needs the women had. In addition, they collected some social and medical information for the study. At the end of the study, intervention and control group women were compared on 15 fetal, infant and maternal health outcomes. Information on these outcomes was taken from two sources: obstetric case-note information (completed for 507 out of the 509 women) and a postal questionnaire sent to the women 6 weeks after delivery (94% replied). Full details of the aims, methods and findings of the trial are given elsewhere (Oakley et al, 1990). All the data, including those from open-ended questions on the postnatal questionnaire, were coded and computerised, and analysed using dBase I I I and SPSS. A number of statistical tests have been applied to these data; for those discussed in this paper the main one is the chi square test: tables carry the p value where this is less than 0.1. Some analyses were done on the total sample and some comparing the intervention and control groups. It should be noted that it was not possible to ascertain from the postal questionnaire whether the women used artificial milk to complement or supplement the breast feeds. For this reason both expressions are used throughout.

FINDINGS Table 1 shows that the intervention and control groups had comparable social and demographic backgrounds. Table 2 shows initial feeding by birth weight above or below 2500 g, social class

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Table 1 Social characteristics of sample Intervention Control Working class Partner unemployed Employed in pregnancy Education completed at or before 16 Mean number of previous LBW pregnancies 1 2 3 Total numbers

77% 21% 33%

72% 20% 35%

31%

31%

85% 11% 4%

86% 12% 2%

255

254

and study group. Significantly more babies weighing over 2500 g were exclusively breast fed in hospital, compared to babies of less than 2500g at birth; 39% compared with 23%. Ten per cent of all women in both groups complemented or supplemented the breast with a bottle feed. There were significant differences in initial feeding in the whole sample by social class (Table 2). Fifty-four per cent of middle class women breast fed their baby completely whilst in hospital, and an additional 21% gave artificial milk as well as breast milk. The equivalent figures for working class women were 32% breast feeding and an additional 11% complementing or supplementing with other feeds. As one of the purposes of the social support intervention was to improve the woman's experience of the antenatal and postnatal period, we had hypothesised that this might be reflected in increased breast feeding rates in the intervention group. Table 2 shows that 38% of the intervention group were breast feeding alone in hospital, compared to 33% of the control group. For breastfeeding women with or without other feeds, the gap closes slightly to 50% of the intervention group and 47% of the control group. There was a trend for intervention women to have slightly higher rates of complete breast feeding and of complemented or supplemented breast feeding. More middle class women tended to be unable to feed in the w a y they had originally intended ( 18 %) compared to working class women ( 12 %).

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Table 2 Initial feeding method by birth w e i g h t , social class and study group Initial feeding method by w e i g h t o f baby

Breast alone Breastand other Bottle alone Tube Bottle and tube Total N=452"

> 2500 g

< 2500 g

N 144 37 186 0 1 368

N 19 25 32 1 7 84

% 39 11 51 1

% 23 30 38 1 8

p
Breast alone Combination Bottle Tube Total N = 408"*

Middle class

Working class

N 60 23 28 0 111

N 95 34 167 1 297

% 54 21 24

% 32 11 56

p <0.0001 Initial feeding method by study group

Breast Breast and other Bottle Tube Total

Baby's condition Premature/low birth weight, tubefed Premature/low birth weight, not tubefed Mouth bruised Would not suck Heart condition Lost weight Topped up because of low blood sugar Not satisfied Total Maternal health Breast problems (sore/uncomfortable breasts; bleeding/cracked nipples) Nipples too large/too small/inverted Anxious/tired LSCS scar/drugs taken/afterpains/ill Milk supply dried up/not enough milk Total Other factors Perceived lack of staff support Staff bottlefed baby against woman's wishes Not enough privacy Problems feeding previous child Changed mind Total

Intervention

Control

N 88 28 115 1 233

N 75 30 120

% 38 12 50

Table 3 Reasons for being unable to feed as originally intended

% 33 13 53

225

N = 458 *** * Data missing for 7 women. ** Insufficient information in records for classification to be carried out for 51 women. *** Data missing for 1 woman.

This p r o b a b l y reflects the fact t h a t m o r e m i d d l e class w o m e n w a n t e d to breast feed their b a b y , and so were more likely to begin breast feeding and find themselves u n a b l e to continue. Reasons for not breast feeding tended to fall into three categories: the b a b y ' s needs or condition m a d e it impossible or inadvisable; the w o m a n herself felt so ill or u n c o m f o r t a b l e that she could not breast feed; a n d perceived lack of support from hospital staff, or lack of privacy. A few w o m e n said they h a d simply c h a n g e d their m i n d a n d did not give a reason. Several w o m e n

18 4 2 3 1 1 1 1 31

8 6 3 I0 11 38

3 1 1 2 5 12

N=30 N.B. Some women gave more than one reason.

gave m o r e t h a n one reason. T a b l e 3 summarises these answers. Some w o m e n begin to breast feed in hospital a n d are advised, for various reasons, to complem e n t or t e m p o r a r i l y s u p p l e m e n t with a bottle feed. D a t a from this s t u d y suggest t h a t very few of these w o m e n c o n t i n u e d to breast feed once they left hospital. O f the 52 w o m e n who were c o m p l e m e n t i n g or t e m p o r a r i l y s u p p l e m e n t i n g in hospital, only 6 (12%) were breast feeding alone by the time they c o m p l e t e d the postnatal questionnaire at a r o u n d 6 to 8 weeks, a n d 38 (73%) of t h e m were bottle feeding only. T h e r e m a i n i n g 16% were still doing both. T a b l e 4 shows t h a t the w o m e n w h o breast fed completely did so for an average of 23 days, i n t r o d u c i n g the bottle a d a y or so prior to giving up. Those who t e m p o r a r i l y c o m p l e m e n t e d or s u p p l e m e n t e d with a bottle breast fed for the much shorter period o f 8 days on average, having i n t r o d u c e d the bottle a r o u n d the third day. T u b e

MIDWIFERY Table 4 Average length of breast feeding and average t i m e of introduction of bottle feeding f o r each combination of feeding method Average duration of breast feeding Breast only 23.4 days Breast and bottle 8.3 days Breast and tube 26.3 days Breast, bottle and tube 36.0 days

Average time of bottle introduction 22.3 3.6 25.5 7.2

days days days days

fed babies whose mothers breast fed with or without additional artificial feeds by bottle were few. However, they continued to breast feed for longer (26 days for those complementing or supplementing by breast alone, and 36 days for those complementing or supplementing by breast and bottle). There was a relationship between the time lag from birth to first suckling and the rates of successful breast feeding at the time of the postnatal questionnaire (PNQ). T w o h u n d r e d and twentyseven women provided data on the timing of the first breast feed. Table 5 shows no significant difference in the distribution of times between women who were breast feeding exclusively or bottle feeding exclusively at the time of the PNQ. Nearly half put the b a b y to the breast within half an hour of delivery. Table 6 sets out the relationship between the type of analgesia received during labour and breast feeding rates in hospital and at the time of completing the PNQ. There were no significant Table 5 Feeding at P N Q b y t i m e lag b e t w e e n birth and putting baby to the breast Exclusively bottle feeding at 6-8 weeks

breast feeding at 6-8 weeks Immediately/within first half hour Half to 1 hour 1 to 4 hours 4 t o 8 hours More than 8 hours Total N =

227

N

%

N

%

61 15 27 5 11

51 13 23 4 9

43 18 24 13 10

40 17 22 12 9

119

108

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differences in hospital breast feeding rates for the different types of analgesia. As expected, those who had a general anaesthetic were least likely to breast feed in hospital (33% compared to 44% on average). Those given no analgesia, entonox or pethidine were most likely to start breast feeding within half an hour of delivery. Those who had an epidural or general anaesthetic mostly started breast feeding more than half an hour after delivery (or after regaining consciousness in the case of women having a general anaesthetic). T h e greatest drop-off in breast feeding occurred for women who had pethidine and first breast fed more than half an hour after delivery; over two thirds of these had stopped breast feeding at the time of the PNQ. T h e average drop-off rate in breast feeding at P N Q was by less than a half. W o m e n who had pethidine or a general anaesthetic had the lowest rates of breast feeding at P N O time (17-18%, compared to 24% on average). Table 7 shows that s~.gnificantly more intervention group w o m e n put their b a b y to the breast within the first hour. By 6 to 8 weeks, 77% of the women in the study had either never breast fed, had completely given up, or had introduced the bottle to supplement one or more of the breast feeds. T h e y were invited to tell us why they had done so by ticking off one or more answers on a pre-set list of responses and adding other reasons if these were not covered. Table 8 gives these responses, together with the n u m b e r of women mentioning each factor. By far the most c o m m o n reason for not breast feeding, or for giving up, was that the w o m a n herself did not like doing it. This was perhaps one of the advantages of having pre-set answers to this question: the women were given permission to express w h a t they m a y have felt to be an unacceptable attitude. O n e quarter of the women responding did not like breast feeding, compared with 14% in Martin and Monk's report (1982). The next most frequently stated reason was competing needs of other children in the family. Sometimes the sheer impracticality of breast feeding on d e m a n d was made very explicit, as in the case of the w o m a n who found herself unable to combine a relaxed breast feeding routine with taking her children to and from school even with

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Table 6 Analgesia during labour and breast feeding rates No analgesia

Entonox

Pethidine

Epidural

General anaesthetic

Total

95

108

122

65

83

473

23 (24%) 18 (19%)

29 (27%) 24 (22%)

31 (25%) 25 (20%)

11 (17%) 18 (28%)

5 (6%) 22 (27%)

99 (21%) 107 (23%)

41 (43%)

53 (49%)

56 (45%)

29 (45%)

~ 27 (33%)

206 (44%)

Still breast feeding Less than half hour*

18 (19%)

16 (15%)

14 (11%)

8 (12%)

3 (4%)

59 (12%)

At PNQ More than half hour*

10 (11%)

14 (13%)

7 (6%)

13 (20%)

12 (14%)

56 (12%)

28 (30%)

30 (28%)

21 (17%)

21 (32%)

1 5 (18%)

105 (24%)

Total Breast feeding in hospital Less than half hour* More than half hour* Total

Total * Post-delivery.

Note: The total in each analgesia group used as denominator.

a rota system. A constantly crying b a b y was another great incentive to bottle feed, as was the belief that not enough milk was being produced. Sometimes this was the w o m a n ' s own opinion, more often that of doctors or other health professionals. Nearly one tenth of the w o m e n said that they had not breast fed, or had given up, because their partner wanted to help feed the baby. I n a few cases the partner actually objected to breast feeding, and three w o m e n said that the disapproval of their mother or mother-in-law had been a factor in their decision to stop. T h e baby-related factors were often given as the reasons for not breast feeding or introducing the bottle. For example, crying, losing or not gaining weight, tube feeding and poor sucking were felt to be sufficient justification. It is noteworthy that the mothers of 6 of the 14 babies who Table 7 Babies put to breast w i t h i n I hour of delivery Intervention N

%

N

%

77

32

59

24

60 103

25 43

77 107

32 44

Put to breast in first hour Put to breast after first hour Never breast fed Total

240

p =

0.03

Control

243

sucked poorly were given pethidine during labour. A small, but important, group of women (12) said that they had been unable to continue breast feeding because of lack of support from hospital staff or other health professionals. Social class differences were not great on the whole. Working class w o m e n were a little more likely to cite breast problems and a crying baby as reasons for stopping breast feeding. T h e main difference between the social classes was in terms of partner's support or preferences being used as a reason for not breast f e e d i n ~ 1 8 % of working class women, compared with 4% of middle class women gave this response, and all those who said their partner did not like breast feeding were working class. H a l f as m a n y middle class women, 13% compared with 29%, said that the reason they did not breast feed was because they did not like it, or because they simply preferred to bottle feed. W o m e n whose b a b y weighed less than 2500 g were more likely to say that the reason for giving up breast feeding was that the b a b y would not suck, or was not gaining enough weight. O n the other hand, the mothers of larger babies tended to give more 'social' reasons: the needs of other children, partner's wish to help with feeding, and the need to make childcare or nursery provision for the baby. These w o m e n were also more likely

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Table 8 Reasons for not starting, or stopping breast feeding and introducing bottle feeding Closed questions

N

%

Woman herself did not like breast feeding

116

25

Breast-related reasons Not producing enough breastmilk (opinion of health professional) Not producing enough breastmilk (woman's opinion) Cracked or inverted nipples

25 12 19

"~ ~ 12

Baby-related reasons Baby cried a lot, thought s/he might be hungry Baby would not suck/slow/frequent feeder Baby not putting on enough weight Baby small/premature, tube fed from birth Baby ill

45 19 19 41 9

"t | I 28

Woman-related reasons Woman ill Woman had caesarean Drugstaken affected baby Woman too anxious Felt too tired to continue

13 3 4 2 16

Social-family related reasons Needs of other children in the family had to come first Husband/partner did not approve of breast feeding Husband/partner wanted to help feed the baby Mother/mother-in-law did not approve of breast feeding Needed to leave baby with another person/nursery Poor experience of breast feeding in previous pregnancy Lack of practical support for breast feeding by hospital staff/midwife No privacy

58 "~ 6 39 3 33 19 12 12 4

| .~

8

N = 467 N.B. Many women gave more than one reason

to cite a crying b a b y as a reason for bottle feeding. M o r e t h a n a q u a r t e r of w o m e n whose b a b y weighed over 2500 g said they d i d not like breast feeding, whereas this reason was given by less than one fifth of mothers of smaller babies. T a b l e 8 summarises responses to closed questions on breast feeding in the p o s t n a t a l questionnaire. I n addition, the w o m e n were asked if there were a n y other reasons, not covered in the list given, for not breast feeding or for i n t r o d u c i n g the bottle. T h e i r answers are in T a b l e 9.

DISCUSSION O n e of the r e c o m m e n d a t i o n s of the T h i r d R e p o r t on present d a y practice in infant feeding (DHSS, 1988) is t h a t there should be a 'search for new ways o f e n c o u r a g i n g breast feeding especially in those sections of the c o m m u n i t y where it is shown

to be low'. T h e S S P O study has highlighted the problems of one such section of the c o m m u n i t y . W o m e n in poor economic circumstances are more likely to have a L B W baby; they are also less likely to breast feed ( M a c f a r l a n e & Mugford, 1984). Whilst a c k n o w l e d g i n g t h a t life's problems are r a t h e r more complex t h a n can be encompassed in a short answer on a postal questionnaire, careful consideration of the reasons given b y these w o m e n for giving u p breast feeding or for not being able to feed as they w o u l d have wished suggests t h a t there are some areas in p o s t n a t a l care which still leave r o o m for i m p r o v e m e n t . W h e r e a s suckling at the breast m a y not be possible for very sick or small babies, p r e m a t u r i t y and low birth weight in themselves do not necessarily rule out successful breast feeding. F u r t h e r m o r e , some w o m e n who perceive their breasts, nipples or

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Table 9 Some of the reasons given for giving up breastfeeding or introducing the bottle

• Open questions Find it inconvenient Feeling depressed Baby slow and frequent feeder Did not want to feed in front of others/no privacy Bottle fed previous child Drugs taken would have affected baby Felt too ill Baby had tooth which caused soreness Hospital policy was to bottle feed small babies Likes to know how much milk baby is taking Does not produce milk in one breast Last baby lost weight because not enough milk Did not get on with breast pump After pains caused too much discomfort Other children wanted to help feed the baby Baby allergic to breast milk Baby given bottle by friend, would not then breast feed Doctors said she was unable to breast feed Baby lost weight Breast feeding too much hassle Had abscess when feeding previous child Revolted by the thought of breast feeding Breasts engorged, no help given to express

milk supply to be inadequate in some way might well be persuaded to persevere, provided that the support given was sufficiently enthusiastic, appropriate and continuous. A notable feature of ~he research of Houston et al (1981) was that none of the women receiving extra breast feeding support gave inadequate milk supply as a reason for stopping breast feeding. Improved support and positive action towards encouraging breast feeding would have enabled several of the women in the study--according to them--to feed their baby as they had wanted to before the birth. Within a supportive environment, in which staff are aware of the external considerations that can influence women's decisions, those who changed their minds from for to against breast feeding could have been given the opportunity to discuss their reservations and at least have given breast feeding a try. Indeed, the fact that a number of women breast fed who had intended to bottle feed does illustrate that there are opportunities to influence women to try to breast feed right up to the birth and beyond. As Jenner (1988) found, the provision of extra advice and support to working class women had

the beneficial effect of increasing breast feeding rates. The breast feeding achievements of mothers of tube fed babies in this study are particularly noteworthy. It takes a great deal of determination and stamina to breast feed a tube fed baby, especially when, as was often the case in this study, women have other young children at home. The strength of this determination is illustrated by the fact that these mothers breast fed even longer than mothers of non-tube fed babies. One explanation could be that, presented with a very small baby, the new mother wishes to give the best possible start and so makes an extra effort. It could be, also, that these mothers benefit from the extra time they have to spend with their baby in hospital, and from the attention and supportive care they and their baby receive. Certainly, as other research has shown (Narayan et al, 1984; Bauchner et al, 1986), low birth weight babies may benefit particularly from the passive immunity derived from breastmilk. Women who introduced the bottle whilst still in hospital breast fed on average for only one third as long as those who did not. Whilst it is preferable, for those who wish to breast feed at all, to be able to do so even for a short time, it does seem from these data that hospital staff should think twice before offering the bottle just because they or the woman herself believe she does not have enough milk or that her nipples are unsuitable for breast feeding. These days, women are often only in hospital for 2 days or less after the birth. For so many of them to be complementing or supplementing a breast feed with artificial milk within that time suggests that hospital staff are not considering the long term implications of this practice for the baby's wellbeing, perhaps preferring the short term benefits of a baby who can be given a bottle in the nursery at night and the calming of a tired and over-anxious mother. As long ago as 1975, Sloper et al found a link between the attitudes of midwifery staff towards breast feeding, feeding schedules, and baby milk formula supplements and the practice of infant feeding, with an increase in breast feeding when staffs attitudes were more positive. The findings of this study serve to emphasise

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the importance of the recommendations of the Department of Health Working Party (1988) on infant feeding that: ' I f a mother wishes to breastfeed, no other fluid should be given to the baby. There is no need for it in a well baby and once feeding other than breastfeeding is begun, successful lactation is jeopardised.' The link between the use of pethidine and the later initiation of breast feeding with women's ability to maintain breast feeding over the first few months, serves to reinforce the findings of other studies (Richards and Bernal, 1971; Brackbill et al, 1974). The use of pethidine should be considered very carefully as a factor in unsuccessful breast feeding, and at the very least, women who have it administered during labour should be given extra support in establishing and maintaining breast feeding. Some of the reasons outlined in Tables 8 and 9 are understandable motives for giving up breast feeding--feeling too ill, taking drugs that would affect the baby, and the baby producing early teeth. However, a number of the reasons given could well have been overcome with an increased amount of help and encouragement from health professionals. Several recent studies have reported inadequacies in the quality of support given to breast feeding women (Graham and McKee, 1979; West, 1980; McIntyre, 1982; McIntosh, 1985). One study in particular was able to demonstrate that increased support, in the form of home visits to women who were breast feeding, enabled those women to breast feed for longer (Houston et al, 1981). There are a number of practical ways in which women may be helped at this time. In a supportive, informative antenatal and postnatal environment the convenience of breast feeding should be set against its inconvenience. Women should have the opportunity to see a mother breast feeding, as well as being given instructions on bow to prepare formula feeds. Thought should be given to ways in which postnatal unhappiness can be mediated or alleviated. The need for privacy should be discussed, and if the woman feels it is a problem it may be possible to

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suggest alternative feeding arrangements. It ought to be possible to allow women time to mull over the unfortunate experiences of the past, and to encourage them by so doing to adopt more positive attitudes to feeding subsequent babies. This could go a tong way towards reversing the trend for mothers to bottle feed later babies if they bottle fed the first (Martin & White, 1988). Mothers should not be given the impression that any hospital has a 'policy' to formula feed low birth weight babies. More practical information on the technicalities of milk production and the benefits of breast feeding could be given, perhaps via articles in women's magazines or through the medium of popular television programmes, so that women can be encouraged to understand what is involved in breast feeding as far as their own body and the baby's needs are concerned. Many of these recommendations are incorporated in the Department of Health's Joint Breastfeeding Initiative (1988). Women with other children are particularly at a disadvantage. They are less likely to be able to attend antenatal classes--either because they have done so before and do not see the need to repeat the experience, or because they have other children and childcare or collecting children from school is difficult. These women may stay in hospital for a shorter period of time after the birth, because of the conflicting needs of their other children. And they may have had experiences with a previous child that have put them off breast feeding. The odds seem to be stacked against their establishing a successful breast feeding routine if they have not done so in a previous pregnancy. The postnatal stay in hospital, however short, could be an ideal time to reverse these odds. An informal talk or discussion, together with a ward routine and staffing policy designed to give women the maximum time with their baby and with supportive others (which includes other mothers) could welt make all the difference for the woman who is undecided about breast feeding, or is having problems getting it established. Such a regime might be extended to encourage discussion of feelings about maternity, relationships, and postnatal unhappiness. The Department of Health (1988) recommendation is that:

26

MIDWIFERY

'All who come in contact with the newly delivered mother should encourage her in gaining confidence in breast feeding a n d accepting that her milk can supply all her b a b y ' s nutritional needs . . . it is also i m p o r t a n t that the father a n d other close family members have confidence in her abilities.' Perhaps a more informative approach to women's partners could help persuade those who w a n t to help feed the b a b y that taking over a large part of the new mother's household a n d childcare responsibilities would be a more beneficial c o n t r i b u t i o n in that it would enable her to breast feed. O n e of the findings of the SSPO study was that the partners of i n t e r v e n t i o n group w o m e n were significantly more likely to help r u n the household than were their control group counterparts. I f health professionals succeeded in mobilising this kind of readily available support, it is likely that breast feeding rates would rise. A greater effort to inform and encourage partners might also help dispel the negative attitude m a n y m e n seem to have towards breast feeding. T h e suggestion made in the 1975 O P C S Survey (Martin, 1978) that y o u n g w o m e n should be given information on breast feeding at school should also be extended to raising y o u n g m e n ' s awareness, well before they become fathers, of the i m p o r t a n c e of providing practical support so that their children m a y be breast fed a n d thus given the best possible start in life. T h r o u g h o u t the Social S u p p o r t in P r e g n a n c y Study, the most c o m m o n suggestion from the w o m e n involved was that more a t t e n t i o n be given to their own feelings a n d opinions. So often, p r e g n a n c y is seen to be a b o u t the production of a baby, a n d the mother is m a d e to feel like a container out of which the p r o d u c t will emerge. T h e frequent complaints from the study w o m e n a b o u t a n t e n a t a l 'cattle-markets' or ' p r o d u c t i o n lines', a n d the feelings of being 'slabs of m e a t ' u n d e r l i n e the alienation of p r e g n a n t w o m e n a n d new mothers from the present system of a n t e n a t a l a n d postnatal care. Indeed, the p r o b l e m is more serious t h a n this: comments such as these suggest that the system is serving to alienate w o m e n from their own body. A shift of emphasis, towards i m p r o v i n g the

emotional as well as the physical wellbeing of the mother, towards finding out a n d respecting her opinions, beliefs a n d feelings, a n d towards involving her p a r t n e r in the provisions of care a n d support can only benefit the mother a n d her baby. I t m a y also b r i n g i m p r o v e m e n t s to the system of a n t e n a t a l a n d postnatal care that will give back to health professionals a real sense of i n v o l v e m e n t in the r e p r o d u c t i o n a n d sustenance of life, instead of seeing themselves as the adm i n i s t r a t o r s - a n d s e r v a n t s - - o f technology.

Acknowledgements Tbis trial was funded by the Department of Health from 1985 to 1988and carried out at the Thomas Coram Research Unit, part of London University's Institute of Education.

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