- Email: [email protected]
The professionalising of breast feeding—Where are we a decade on?
Midwifery 29 (2013) e32–e33
Contents lists available at SciVerse ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Response to Letter to the Editor
The professionalising of breast feeding—Where are we a decade on?
Dear Editor Thank you for the opportunity to respond to the letter to the editor in relation to our article published earlier this year. We appreciate the author engaging in the issues and concerns we raised and would like to thank them for their response. The main argument in our original paper remains unchanged— that breast feeding has become professionalised in such a way that women are not seen as the experts, feel devalued and lack confidence. It seems the women who most want to breast feed feel this most keenly and are devastated if things to do not work out. Our current approach to breast feeding also undervalues the relationship between the woman and her baby, and the contribution that the baby brings as the mother and baby learn how to breast feed together (Thompson et al., 2011; Burns et al., in press). We accept and agree that women both expect and need professional support, however we are concerned about the manner in which that support is provided. The focus of this support appears to privilege the nutritional aspects of breast feeding and breast milk to the detriment of a more holistic view of the emotional and social support needs of women (Burns et al., 2012). Our recent work also highlights a health professional tendency to provide ‘expert’ instruction based on the ‘technical’ aspects of breast feeding (Burns et al., in press). Even more concerning is that too many midwives and services interpret best practice principles as outlined in the ‘Ten Steps to successful breast feeding’ as rules, and proceed to implement the steps in a rigid manner. An exclusive focus on nutrition, rules or expertness undervalues the other, significant, needs that women have (caring for the rest of the family, reassurance, rest, etc.) that are critical in the maintenance of breast feeding past the initial couple of weeks. The importance of these needs is diminished when the entire focus is on breast feeding as a technical activity. It is however a key part of woman to woman support. It would appear that pre-registration midwifery programs, particularly those that provide a postgraduate qualification on top of nursing, have struggled to adequately prepare midwives with the communication skills needed to support relationship-based interactions around breast feeding. Subsequent Lactation Consultant (LC) education does not appear to ameliorate these deficiencies. Many of the LC’s practices observed in our recent work, tended to incorporate ‘medicalised’ approaches to the ‘management’ of breast feeding ‘for’ women. Yet there were also examples of more relationship focussed approaches to LC breast-feeding support (Burns et al., in preparation). DOI of original article: http://dx.doi.org/10.1016/j.midw.2012.11.008 0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2012.11.007
Indeed changes with the IBCLC requiring LCs to have a greater focus on developing and demonstrating expert communication skills and the ability to build therapeutic relationships with women may already be yielding results. It is also the case that the institutions in which midwives practice may not offer them the opportunity to use a relational approach in their work within a model of care that supports this (Dykes, 2006; Burns et al., in press). As communication skills have been shown time and again to be important in supporting women as they learn to breast feed (Dykes, 2006; Schmied et al., 2011; Burns et al., in press), it behoves all of us involved in midwifery education to remedy this situation. LCs should not be there to remediate a breakdown in our midwifery education systems or to address policy and service models that are poorly designed and not women centric. This appears to be happening. That we are concerned that breast feeding is being professionalised is not new. From as early as the mid 1990s LCs themselves suggested they may be creating rigid rules of breast feeding, arguing that this had the potential to emphasise the health-care profession’s need to control infant feeding, as was done by others in the past (Pessl, 1996). Palmer (1991) also argued it would again be easy to create the image that breast feeding is only successful when it is managed by the expert and this is what concerns us. Maybe these concerns have been forgotten as the role of the LC has grown. The trend towards normalisation of LCs renders breast feeding a technical and challenging activity requiring expert input from the beginning. In Australia LCs are becoming the ‘necessary person’ required to help with breast feeding in the same way the obstetrician has become the ‘necessary person’ for birthing. However, we see LCs as a useful adjunct to provide expert help with technically difficult feeding outside the norm; for example a pre-term baby. The key issue is getting the balance right between professional support, woman to woman support and policy. We certainly agree that the presence of the NMAA and its activities in the 1970s and 1980s is not the one single factor that influenced the rise in rates during the 1970s and 1980s and that in fact the impetus for NMAA can perhaps be attributed to the factors that are mentioned. Our reading of the graph and the pattern in breast-feeding rates is that the introduction of the BFHI and the increasing number of LCs does not appear to have had any positive impact on rates of sustained breast feeding. This is a concern and explains why we undertook this analysis to see if a trend was emerging that would support the shift to BFHI and increase in LCs. We would strongly agree with the author that women do not always comply with advice. The many women with whom we
Response to Letter to the Editor / Midwifery 29 (2013) e32–e33
have conducted interviews over the past decade certainly give a strong message that they will do what they want in spite of professional advice. This is stated most strongly when women feel they have not been listened to, when their concerns have been largely ignored or neglected, or when they have felt belittled by the professional in their interactions with them. Breast feeding support by professionals is not just advice, it is about listening and watching, and supporting (Thompson et al., 2011) and reinforcing women’s and babies’ own confidence and competence within their relationship. Sheehan et al. (2010) showed that ‘bad’ support in fact lowered women’s confidence to breast feed and appeared to have a negative effect on breast feeding. Certainly if we do not listen to the individual needs of women, the advice given may in fact not be what the women need to sustain breast feeding and therefore the women will do what they feel is best (and without appropriate support this may very well include weaning). Similarly dogmatic instruction to multigravida women who want to use a dummy, because this is against the baby friendly rules of a hospital, will be counterproductive and ignored. We hope our work continues to raise debate, discussion and reflection in those of us committed to supporting women and babies learning to breast feed.
Sheehan, A., Schmied, V., Barclay, L., 2010. Complex decisions: theorising women’s infant feeding decisions in the first six weeks post-birth. Journal of Advanced Nursing 66, 371–380. Thompson, R., Kildea, S., Barclay, L., Kruske, S., 2011. An account of significant events influencing Australian breast feeding practice over the last 40 years. Women and Birth 24, 97–104.
Professor/Director Lesley Barclay, RM, PhDn, Research Fellow Jo Longman, MPH, PhD University Centre for Rural Health—North Coast, University of Sydney, PO Box 3074, Lismore, NSW 2477, Australia E-mail address: [email protected] (L. Barclay)
Professor of Maternal and Infant Health Virginia Schmied, RN, RM, PhD, Lecturer in Midwifery Elaine Burns, RM, PhD School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia
(A/Professor) Athena Sheehan, RM, MN, PhD Faculty of Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia
References Burns, E., Fenwick, J., Sheehan, A., Schmied, V. Mining for liquid gold: midwifery language and practices associated with early breastfeeding support. Maternal and Child Nutrition, http://dx.doi.org/10.1111/j.1740-8709.2011.00397.x, in press. Burns, E., Schmied, V., Fenwick, J., Sheehan, A., 2012. Liquid gold from the milk bar: constructions of breastmilk and breastfeeding women in the language and practices of midwives. Social Science and Medicine 75, 1737–1745. Burns, E. Sheehan, A. Fenwick, J, Schmied, V. Facilitation of breastfeeding: lactation consultant language and practices in the first week after birth, in preparation. Dykes, F., 2006. Breastfeeding in Hospital: Mothers, Midwives and the Production Line. Routledge, Oxon. Pessl, M.M., 1996. Are we creating our own breastfeeding mythology? Journal of Human Lactation 12, 271–272. Palmer, G., 1991. Give breastfeeding back to the mothers. Journal of Human Lactation 7, 1–2. Schmied, V., Beake, S., Sheehan, A., Mccourt, C., Dykes, F., 2011. Women’s perceptions and experiences of breastfeeding support: a metasynthesis. Birth 38, 49–60.
e33
Biostatician Margaret Rolfe, MStat, PhD University Centre for Rural Health—North Coast, University of Sydney, PO Box 3074, Lismore, NSW 2480, Australia
Professor of Midwifery Jennifer Fenwick, RM, PhD Griffith University, Logan Campus, University Drive, Meadowbrook QLD 4131, Australia Received 23 October 2012
n
Corresponding author. Tel.: þ61 02 6620 7570.
Contents lists available at SciVerse ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Response to Letter to the Editor
The professionalising of breast feeding—Where are we a decade on?
Dear Editor Thank you for the opportunity to respond to the letter to the editor in relation to our article published earlier this year. We appreciate the author engaging in the issues and concerns we raised and would like to thank them for their response. The main argument in our original paper remains unchanged— that breast feeding has become professionalised in such a way that women are not seen as the experts, feel devalued and lack confidence. It seems the women who most want to breast feed feel this most keenly and are devastated if things to do not work out. Our current approach to breast feeding also undervalues the relationship between the woman and her baby, and the contribution that the baby brings as the mother and baby learn how to breast feed together (Thompson et al., 2011; Burns et al., in press). We accept and agree that women both expect and need professional support, however we are concerned about the manner in which that support is provided. The focus of this support appears to privilege the nutritional aspects of breast feeding and breast milk to the detriment of a more holistic view of the emotional and social support needs of women (Burns et al., 2012). Our recent work also highlights a health professional tendency to provide ‘expert’ instruction based on the ‘technical’ aspects of breast feeding (Burns et al., in press). Even more concerning is that too many midwives and services interpret best practice principles as outlined in the ‘Ten Steps to successful breast feeding’ as rules, and proceed to implement the steps in a rigid manner. An exclusive focus on nutrition, rules or expertness undervalues the other, significant, needs that women have (caring for the rest of the family, reassurance, rest, etc.) that are critical in the maintenance of breast feeding past the initial couple of weeks. The importance of these needs is diminished when the entire focus is on breast feeding as a technical activity. It is however a key part of woman to woman support. It would appear that pre-registration midwifery programs, particularly those that provide a postgraduate qualification on top of nursing, have struggled to adequately prepare midwives with the communication skills needed to support relationship-based interactions around breast feeding. Subsequent Lactation Consultant (LC) education does not appear to ameliorate these deficiencies. Many of the LC’s practices observed in our recent work, tended to incorporate ‘medicalised’ approaches to the ‘management’ of breast feeding ‘for’ women. Yet there were also examples of more relationship focussed approaches to LC breast-feeding support (Burns et al., in preparation). DOI of original article: http://dx.doi.org/10.1016/j.midw.2012.11.008 0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2012.11.007
Indeed changes with the IBCLC requiring LCs to have a greater focus on developing and demonstrating expert communication skills and the ability to build therapeutic relationships with women may already be yielding results. It is also the case that the institutions in which midwives practice may not offer them the opportunity to use a relational approach in their work within a model of care that supports this (Dykes, 2006; Burns et al., in press). As communication skills have been shown time and again to be important in supporting women as they learn to breast feed (Dykes, 2006; Schmied et al., 2011; Burns et al., in press), it behoves all of us involved in midwifery education to remedy this situation. LCs should not be there to remediate a breakdown in our midwifery education systems or to address policy and service models that are poorly designed and not women centric. This appears to be happening. That we are concerned that breast feeding is being professionalised is not new. From as early as the mid 1990s LCs themselves suggested they may be creating rigid rules of breast feeding, arguing that this had the potential to emphasise the health-care profession’s need to control infant feeding, as was done by others in the past (Pessl, 1996). Palmer (1991) also argued it would again be easy to create the image that breast feeding is only successful when it is managed by the expert and this is what concerns us. Maybe these concerns have been forgotten as the role of the LC has grown. The trend towards normalisation of LCs renders breast feeding a technical and challenging activity requiring expert input from the beginning. In Australia LCs are becoming the ‘necessary person’ required to help with breast feeding in the same way the obstetrician has become the ‘necessary person’ for birthing. However, we see LCs as a useful adjunct to provide expert help with technically difficult feeding outside the norm; for example a pre-term baby. The key issue is getting the balance right between professional support, woman to woman support and policy. We certainly agree that the presence of the NMAA and its activities in the 1970s and 1980s is not the one single factor that influenced the rise in rates during the 1970s and 1980s and that in fact the impetus for NMAA can perhaps be attributed to the factors that are mentioned. Our reading of the graph and the pattern in breast-feeding rates is that the introduction of the BFHI and the increasing number of LCs does not appear to have had any positive impact on rates of sustained breast feeding. This is a concern and explains why we undertook this analysis to see if a trend was emerging that would support the shift to BFHI and increase in LCs. We would strongly agree with the author that women do not always comply with advice. The many women with whom we
Response to Letter to the Editor / Midwifery 29 (2013) e32–e33
have conducted interviews over the past decade certainly give a strong message that they will do what they want in spite of professional advice. This is stated most strongly when women feel they have not been listened to, when their concerns have been largely ignored or neglected, or when they have felt belittled by the professional in their interactions with them. Breast feeding support by professionals is not just advice, it is about listening and watching, and supporting (Thompson et al., 2011) and reinforcing women’s and babies’ own confidence and competence within their relationship. Sheehan et al. (2010) showed that ‘bad’ support in fact lowered women’s confidence to breast feed and appeared to have a negative effect on breast feeding. Certainly if we do not listen to the individual needs of women, the advice given may in fact not be what the women need to sustain breast feeding and therefore the women will do what they feel is best (and without appropriate support this may very well include weaning). Similarly dogmatic instruction to multigravida women who want to use a dummy, because this is against the baby friendly rules of a hospital, will be counterproductive and ignored. We hope our work continues to raise debate, discussion and reflection in those of us committed to supporting women and babies learning to breast feed.
Sheehan, A., Schmied, V., Barclay, L., 2010. Complex decisions: theorising women’s infant feeding decisions in the first six weeks post-birth. Journal of Advanced Nursing 66, 371–380. Thompson, R., Kildea, S., Barclay, L., Kruske, S., 2011. An account of significant events influencing Australian breast feeding practice over the last 40 years. Women and Birth 24, 97–104.
Professor/Director Lesley Barclay, RM, PhDn, Research Fellow Jo Longman, MPH, PhD University Centre for Rural Health—North Coast, University of Sydney, PO Box 3074, Lismore, NSW 2477, Australia E-mail address: [email protected] (L. Barclay)
Professor of Maternal and Infant Health Virginia Schmied, RN, RM, PhD, Lecturer in Midwifery Elaine Burns, RM, PhD School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia
(A/Professor) Athena Sheehan, RM, MN, PhD Faculty of Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia
References Burns, E., Fenwick, J., Sheehan, A., Schmied, V. Mining for liquid gold: midwifery language and practices associated with early breastfeeding support. Maternal and Child Nutrition, http://dx.doi.org/10.1111/j.1740-8709.2011.00397.x, in press. Burns, E., Schmied, V., Fenwick, J., Sheehan, A., 2012. Liquid gold from the milk bar: constructions of breastmilk and breastfeeding women in the language and practices of midwives. Social Science and Medicine 75, 1737–1745. Burns, E. Sheehan, A. Fenwick, J, Schmied, V. Facilitation of breastfeeding: lactation consultant language and practices in the first week after birth, in preparation. Dykes, F., 2006. Breastfeeding in Hospital: Mothers, Midwives and the Production Line. Routledge, Oxon. Pessl, M.M., 1996. Are we creating our own breastfeeding mythology? Journal of Human Lactation 12, 271–272. Palmer, G., 1991. Give breastfeeding back to the mothers. Journal of Human Lactation 7, 1–2. Schmied, V., Beake, S., Sheehan, A., Mccourt, C., Dykes, F., 2011. Women’s perceptions and experiences of breastfeeding support: a metasynthesis. Birth 38, 49–60.
e33
Biostatician Margaret Rolfe, MStat, PhD University Centre for Rural Health—North Coast, University of Sydney, PO Box 3074, Lismore, NSW 2480, Australia
Professor of Midwifery Jennifer Fenwick, RM, PhD Griffith University, Logan Campus, University Drive, Meadowbrook QLD 4131, Australia Received 23 October 2012
n
Corresponding author. Tel.: þ61 02 6620 7570.