Birth Health Life


Thursday, 20 July 2017

Cultural Barriers to the Initiation of Breastfeeding

Breastfeeding peer support on the post natal ward is different to supporting new families in the community clinics. Here in the ward I
draw upon my breastfeeding support skills and my experience as a birth doula combined.  The whole emotional and hormone-rich atmosphere is almost like being in the birth-room still, but not quite. I'm with mothers and babies their partners at one of the most intense and pivotal times of each of their individual and family lives. Arrival on earth, adaptation to new environment, and the beginning of feeding from the breast instead of being fed via the umbilical's a big day for everyone.

I am mindful of the specialness of this time, and of the new family's need for privacy, combined with their needs for varying degrees of breastfeeding support. I'm mindful of the need to balance imparting only the most necessary information with supporting the prevailing right brain state of the mother. I am privileged to bear witness to some incredibly special moments. The first time a mother saw her baby's open eyes. The first time a grandmother saw her brand new grandson. Parents unwrapping and inspecting their child for the very first time. Having someone like me spending time with new mums and babies and their partners on the ward to help with the initiation of breastfeeding is only a very small part of how our culture needs to change to support breastfeeding families. The information about how breastfeeding actually works, and what can mess it up, needs to be out there in our species collective consciousness so that we all know what the hell we're doing when it comes to the nurturing and nourishment of the youngest and most vulnerable among us...because they're our future, right?

  I see the coterie arrive from delivery suite a few hours after birth, mum and belongings wheeled on her bed, partner wheeling the newly born one in a Perspex crib, across the first threshold from birth room to a new place, where mums recover in their beds, and wrapped and hatted babies sleep in Perspex cots. Pretty hats and knitted blankets. Mobile phones taking pictures, one mil syringes collecting colostrum for reluctant feeders. Lots of them. (You never see that on the soaps when there's a new baby)  Baby asleep in the Perspex. Mum high and awake and shattered at the same time. How is this supposed to work?  'About 2 hours after birth, newborns often go into a long sleep stretch, especially when mother and baby are separated.' ~ Nancy Mohrbacher , italics mine.

So when and how are mothers and babies first separated? We might not consider a mother recovering in bed, and her baby next to her in his Perspex crib to be separated, but the baby may feel differently about that. For the duration of pregnancy, the baby's environment has been his mother, and that is the environment where he best recovers from birth and adapts to life outside the womb. His earth-side environment is her skin, her belly, her breasts. Where the birth has been straightforward and the baby healthy, the first separation from the baby's point of view, usually happens in the delivery suite, not long after birth.  Usually, the expectation is that he will be weighed, and dressed. Usually, when the time comes to move to the post natal ward, he is put into a Perspex cot, covered with a blanket, and wheeled to the ward whilst his mother is wheeled on her bed. 

Most mammals would struggle with this kind of disturbance to their basic need to be undisturbed at this crucial time, but the thing about human mothers is that we bravely and selflessly adapt to the 'needs' expectations and culture of those around us.

I wasn't prepared for the number of babies and mums who would need help to get breastfeeding started, unlike the home-births I've seen as a doula where this has never really been a thing. (Of course babies born at home can also struggle to latch at first for a number of reasons and sometimes for no apparent reason) As a doula, I prepare families for the Golden 'hour' after birth when mum's oxytocin levels are the highest they will ever be in her life. Oxytocin is the hormone concerned with love, trust, lovemaking, bonding, and feeding.  We plan to make sure to guard this precious time, and it might last for an hour, two hours, eight hours, depending on the mother's needs and wishes. The room remains warm and dark and quiet, just as it had during labour, to not interrupt the flow of hormones which keep the labour progressing. Now those same hormones are peaking even higher, the ecstasy of that hot wet little body on her skin, eyes meeting for the first time...precious easily lost.  It's a continuum...lovemaking, labour, bonding, breastfeeding...same hormones, same simple requirements of privacy, safety, warmth and a neocortex undisturbed by too much language, talk, or thinking.

Skin-to-skin is where a newly born person gets great comfort in his new environment, and prepares to feed.  Skin to skin with her baby is where a person who has just given birth forgets her pain in a flood of hormones so high she is capable of an ecstatic state (just how much depth of experience new mothers are robbed of in our culture where we do not prepare properly and give this time the respect it calls for) and begins to bond with the person she must now nurture and nourish.

As a doula
, at a homebirth, I might see her still wrapped up in her bed skin to skin with her new one when I leave, hours after the birth.  She may still be there when I return the following day.  I encourage frequent, prolonged periods of gorgeous, ecstatic, uninterrupted cuddling and loving and will bring you teas and cakes and soups and nourishing foods that you love, and get on with the stuff that needs doing whilst you do glorious wonderful nothing but cuddling.

As a breastfeeding peer supporter, on the ward, I will sometimes witness something different. A tense, slightly bewildered and anxious looking hasn't fed, is still asleep, and the midwife is asking her to express colostrum into a syringe. 

'Skin to skin? Oh yes, we did that on delivery suite. I don't think it worked though, he still isn't waking for a feed'

as she looks at her baby wrapped up in his Perspex cot. This is how popular media portrays a woman and baby in a postnatal ward, the baby alone in his see through box. This represents a 'satisfied' baby put 'down to sleep' until the clock dictates another feed...which is 'normal' isn't it?  How our language betrays the scant intellectual knowledge we humans collectively have about how breastfeeding works. Babies are still hardwired the same as they were tens of thousands of years ago, expecting to be carried and held most of the time, with free access to the breast for very frequent feeds. How different are our cultural norms, and the culture of separation begins early. There are some outdated ideas still firmly rooted out there about the cuddling of babies. Spoiling them and rods for backs are the obvious. More deeply, I suspect that in cuddling our own infants we are connected back into how we were cuddled and parented ourselves as babies. Or not of course. Sometimes  all of this stuff combined with the thinking brain gets in the way of instinctive behaviour. The answer lies in the action.

How to unwrap this situation? By suggesting she unwraps her baby, and try some cuddling together with him if she wants. 

 By suggesting t
he Biological Nurturing (aka BN, or laid back breastfeeding) position which will release a flood of hormones, and works whether skin is touching skin, or not.  By explaining that her baby won't get cold when undressed down to a nappy, if his chest and abdomen are against hers, and both of them are covered with a snuggly blanket. Explaining (preferably in a more teachable moment, during ante-natal preparation) that after birth, babies display breastfeeding behaviours when laid on their mother's abdomen (or across her chest if there's a delicate Caesarean incision) and that these behaviours are in-born reflexes, stimulated by being on their mother's belly, smelling her skin and her milk, and are Nature's design to help the baby to begin feeding.  By explaining that babies don't need to be wide awake before going to the breast. By telling this mama that having her baby on her like this, the feeling of his weight and skin, the smell of his head without that pretty hat (that intoxicating scent!) will prepare her body for feeding, with a flood of hormones.... Oh wait... I don't have to tell her that now that her baby is on her because she's living it. I'm watching as she's melting into the dyad that they are together, changing from tense and anxious to flushed and loved up, glazed, not listening to me anymore. Those hormones are working their magic. I swear I can sense the rise in oxytocin that's present here. I'm just there to reflect that back to her, smiling, nurturing her increasing confidence in her own body's ability to nurture this new little being.  These two are where they belong...together.

How to further unwrap this situation?  It's simple, but complex, because it's wrapped up in culture, habits, and expectations and 'because that's how we've always done it'.  I am a lay person, who pops up to the ward for a bit to help out. Do I dare to suggest to the hardworking overstretched angels that are our midwives with far more knowledge and experience than I, that I have a suggestion to improve the way breastfeeding is initiated on the ward? Changing culture isn't easy.  My suggestion is simple, and it has been said by greater people than I, many times before.

I suggest that, where possible, we don't separate mother and baby.  There, I said it. 

But what is meant by separation? I never saw my mother again after she birthed me. That's separation. My second son was ill immediately following his premature birth and was in special care for weeks. That was separation. My first son spent his first night in the hospital nursery down the corridor as was the culture 30 years ago, and we no longer do that now we know that it's separation too.  But what about the more subtle forms of separation like the expectation that babies will be dressed before leaving delivery suite for the post natal ward? With a hat on. I know the midwives always ask, 'do you want me to dress your baby?' but which mum straight after giving birth is going to say 'No thank you, actually I would prefer to transfer to the ward wrapped up with him on my chest in skin to skin.'?  That would be like me saying 'No thank you I'd like a small glass please' when I've asked for a New Zealand Sauvignon and the bar person says 'Large glass, yes?'  Of course, I nod and smile and say 'Yes please!' Upselling is just manipulating cultural compliance after all.

Labouring women need privacy, safety, warmth and no neocortical stimulation to ensure that adrenaline is at a minimum so that oxytocin can flow. Same for early initiation of breastfeeding.  What happens when women leave the house in early labour to go into the hospital to give birth?  Many times, that labour slows right down because being disturbed has adrenalized her.  The same can happen if women have to change rooms in the hospital in early labour.  Mammals choose to birth in familiar surroundings, because the adrenaline is lowest here. For human mammals, 'birthing' doesn't end when the placenta is born. It incorporates that hour or so afterwards when on the  un-medicated mother's chest the healthy term baby displays up to 20 different inborn behaviours which have the purpose of finding the breast and transferring milk. The mother is experiencing an oxytocin high and bonding is happening. The sensitivity around this time is acute.

Moving away for a moment from the birth room to normal life, there is a thing called the 'Doorway Effect' . I just experienced it when I sat down at the kitchen table to write this and it started me thinking and making connections. I've got my coffee, my notebook, my reference books, and been typing for a few minutes. Suddenly I remember that I'm expecting a call and my mobile is still charging upstairs. I get up, and charge upstairs myself. I head for the bedroom, I know that I'm headed for the bedroom, but when I get in there....what the hell am I doing in here?  I know I came up here for something...but what? That's the Doorway Effect. Basically the brain only hangs onto thoughts and information for a limited period of time, before discarding it in order to keep room clear for new stuff to come in. To the brain, leaving one room for another seems like a good time to purge the memory in favour of whatever is going on in the new space.  Something happens in our brains when we move from one space to another. Returning to the birth room, we could  at the very least consider the possibility that moving out of the safe birth space to transfer to the postnatal ward might cause a rise in adrenaline and a corresponding drop in oxytocin. Is there also a corresponding 'Doorway Effect' where birth room conditions such as privacy and  and expectations of behaviour are left behind to make room for the next experience of being on the ward among strangers, all before the birth room occurrences such as bonding and breastfeeding initiation are fully complete. 

Wherever possible, our cultural habit should be that mums and babies are not separated. This could be especially important for when something potentially stressful, like moving rooms, is happening to either of them.

The 'Doorway Effect' has been found true for intellectual experience, but what about the birth experience? What about that timeless space where two souls who have spent nine months as close as two people can get, finally get to look one another in the eye? Might that magic hormonal spell be broken by the passing through of the doorway from familiar birth space to the busy post natal ward full of strangers and their crying babies? Might there be an ancient, mammalian survival mechanism whereby bonding temporarily shuts down in favour of survival, in the presence of adrenaline? Might this interrupt the initiation of breastfeeding Might we mitigate the effect of this using skin-to-skin during transfer to the ward?

I don't know the answer to these questions, but I do know that larger numbers of women are struggling with initiating feeding on the ward than I expected.  I do know that when we unwrap the baby and get them back together I can see the effects of the increased oxytocin flow.  I do suspect that unless myself or a midwife suggests to many mothers that they resume skin-to-skin or at least cuddle their baby, many babies would remain sleeping in their Perspex world whilst their mothers wait for them to wake up and those precious golden first hours and oxytocin highs ebb away.

  I suspect that changing the culture that expects mothers and babies to be separated like this for more time than they spend cuddling together might help with breastfeeding initiation

I also suspect that if we didn't separate them in the first place, with that simple, innocuous expectation that babies need to be clothed more than they need skin-to-skin in the first hours, that we might possibly see fewer struggles later on in the ward.

I know this isn't the answer to all the problems that mothers and babies experience with breastfeeding, and I'm not reinventing the wheel here, I know. I feel this area needs looking at again from the perspective of the baby whilst we are asking ourselves why so many mothers and babies struggle with breastfeeding in hospital.

There is a large body of research supporting skin-to-skin for bonding, temperature regulation, metabolic regulation including blood sugar stability, breathing regulation, and the initiation of breastfeeding. A Cochrane Review article based on 30 studies concluded that skin to skin soon after birth lead, among other benefits, to more likelihood of breastfeeding and breastfeeding for longer. (Moore, Anderson, & Bergman 2007)

References: Breastfeeding Answers Made Simple ~ Nancy Mohrbacher  IBCLC FILCA 2010
An Introduction to Biological Nurturing ~ Suzanne Colson RM Ph.D 2010

I would love to hear your thoughts around this...did this culture impact your breastfeeding experience?  Or are you a healthcare professional working in the postnatal wards?  Please leave your comments below.
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  1. I had a fantastic breastfeeding experience and my daughter was suckling only 15 minutes after her birth as the midwife encouraged me to bring baby to breast. So grateful to have been at Brighton hospital where skin to skin is hugely encouraged.

    1. Thats fantastic! BSUH is an fantastic hospital trust, such amazing midwifery care, and so lovely to hear about your experience, thank you for taking the time to read and comment x

  2. I have email notifications from several commenters, but cannot see or access the comments yet on my blog...apologies. Thank you for commenting, keep them coming, hopefully I will figure out how to get your comments to appear here x Jil

  3. Reading this made me sad. Indeed it would only be natural to follow our instincts and let nature take its course but new mothers often find themselves separated from their newborns for ridiculously long durations just because of protocol. I still feel so sorry to my firstborn who was separated from me after an unexpected cesarian for 1 hour. My third birth was a homebirth where baby latched on while I was still in the birth tub - and it felt exactly right. I loved reading the article as it expressed so well how I feel about this situations, these women are lucky to have you there!


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