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Obstetricians: Buckle Down and Go the Extra Mile
Dr Shek Wan-man Noel
MBBS, FHKAM (O&G), FHKCOG, FRCOG, RCOG Cert (Maternal Fetal Med)
Consultant, Queen Mary Hospital
I was fortunate enough to be involved in preparing Queen Mary Hospital for the designation as Baby-friendly Hospital (BFH). Looking back, I could see myself and my colleagues transforming. As obstetricians, we are aware that breastfeeding confers medical, economical, societal and environmental advantages, and we know that support for breastfeeding is part of obstetric service. However, we are often occupied with or even overwhelmed by the rapid advancements in various aspects of the specialty. Accreditation for BFH was a golden opportunity to direct our focus in restructuring and reinforcing breastfeeding support in our service.
As maternity health care professionals and advocates for women's health who work with other obstetric and paediatric health care providers, obstetricians are obligated to facilitate women to achieve their infant feeding goals. The breastfeeding rate on hospital discharge in Hong Kong increased from 19% in 1992 to 87.2% in 20191. However, the exclusive breastfeeding rate at 4 months was only 29.1% in 20182. Apparently, many mothers started breastfeeding, but the majority did not sustain. Nobody can be in a better position than obstetricians to assist women to make informed choices about infant feeding, offer anticipatory guidance, support normal lactation and manage breastfeeding problems.
Previous studies have shown that obstetricians and residents have reported that their training in infant nutrition was inadequate and their practices were found discrepant with what were recommended for promoting breastfeeding3,4. Obstetricians and residents should be adequately trained and continuously educated such that they can provide accurate and unbiased information about breastfeeding and be prepared to support women when they encounter breastfeeding problems. They should also be equipped with the knowledge of local and regional breastfeeding support services where patients can be referred for additional breastfeeding support after delivery. In addition to knowledge and practical skills, obstetricians' attitude to their responsibility for safeguarding infant feeding are equally important and are key influences on breastfeeding success.
Taking a breastfeeding history, identification of concerns and risks for breastfeeding difficulties, as well as a breast assessment, are recommended by the American College of Obstetricians and Gynecologists (ACOG) as part of prenatal care5. Women should be counselled about the benefits of breastfeeding, starting as early as the first trimester. Encouragement from health care providers have been shown to increase breastfeeding initiation, especially among low-income, young, less-educated or single women6. A patient-centered approach should be adopted to allow the woman and her family to anticipate challenges, develop strategies to address them and to collaborate to develop an infant feeding plan5. Obstetricians can also help to clarify misconceptions about breastfeeding, for example, those associated with maternal hepatitis B infection. It has been shown that the infection was one of the reasons for persistently low breastfeeding rate7.
The World Health Organization's ‘Ten Steps to Successful Breastfeeding’ is an evidence-based set of practices which support breastfeeding physiology, including early skin-to-skin care, enabling rooming-in and feeding on demand. These steps should be incorporated into maternity care to increase the likelihood that a woman will initiate and sustain breastfeeding. Obstetricians should be aware that Caesarean delivery is associated with delayed lactogenesis, whereas unmedicated spontaneous vaginal delivery is associated with positive breastfeeding outcomes. Women who undergo Caesarean delivery may need extra support to initiate and sustain breastfeeding. Also, mother-friendly practices should be encouraged, such as non-pharmacological pain relief, mobilization and labour support by birth partners.
Women should be supported in their informed decision to infant feeding. Obstetricians should collaborate with lactation consultants and infant care providers to manage breastfeeding problems, such as pain, perceived or actual low milk supply, breast infection and maternal medication safety.
Breast pain of various degrees is common in breastfeeding women, at the same time, pain is a common cause of premature weaning. Early nipple pain may indicate a need for checking of positioning and latching. On the other hand, causes of persistent pain include dermatitis, infection, vasospasm, functional pain and other rare conditions should be investigated. Women should be referred to lactation consultants for further management when needed. It is important for obstetricians to be aware that women are at risk of depression when they experience breastfeeding problems, and they should be screened, managed and referred as appropriate.
Women with preterm infants may encounter challenges, including delayed onset of lactation and insufficient milk. Obstetricians can help women to make an informed decision to breastfeed in NICU and provide appropriate support. Both options of expressed breastmilk and feeding from the breasts should be discussed.
Low milk supply is a common concern. The commonest cause of low milk supply is inadequate breast stimulation. Evaluation by a lactation consultant to ensure frequent breast stimulation and milk removal is the most effective strategy to increase milk production.
Most medications are safe to use during breastfeeding. Obstetricians should consult lactation pharmacology resources for up-to-date information on individual medications to avoid women discontinuing breastfeeding unnecessarily. LactMed is a free resource updated monthly from the National Institute of Health National Library of Medicine and available online or as an app. Before prescription, careful assessment of the infant is necessary in all cases, particularly in those who are preterm or sick. Counselling regarding medication use during lactation should address the risk of drug exposure through breastmilk and the risks of interrupting lactation. For example, breastfeeding can be continued without interruption after the use of iodinated contrast during a computed tomography or gadolinium contrast with magnetic resonance imaging.8 For women needing contraception, non-hormonal contraceptive methods are preferred as oestrogen-containing contraceptives may reduce milk supply.
In addition, neonatal management protocols can be developed in collaboration with paediatricians to facilitate initiation and sustaining breastfeeding. Strategies can be revamped in monitoring of newborns with risk factors so as to minimize mother-baby separation, for example, monitoring for early onset group B streptococcus disease and neonatal hypoglycaemia. Treatment protocols, like buccal glucose gel application for mild neonatal hypoglycaemia, can reduce separation, infant formula supplementation and also encourage sustaining breastfeeding.
Policy and Breastfeeding in the Community
Obstetricians should support women and encourage policies which allow women to integrate breastfeeding into their daily lives and the workplace. The ACOG recommends that obstetricians be at the forefront of policy efforts. The Baby-Friendly Hospital Initiative was first launched in 1991 by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to give every baby the best start in life by removing breastfeeding barriers in health facilities and to encourage health facilities, especially maternity hospitals, to implement the ‘Ten Steps to Successful Breastfeeding’. Obstetricians are important players in achieving the goals.
The International Code of Marketing of Breast-Milk Substitutes was developed by the WHO and UNICEF in 1981to promote breastfeeding. Obstetricians should ensure no promotion of products (including breastmilk substitutes, feeding bottles and teats) in the health care facilities. Health care providers should not receive gifts or personal samples, nor pass these samples to the women.
Policies and facilities to create a breastfeeding-friendly workplace should be advocated to accommodate the breastfeeding needs of women at work. Provision of appropriate space and privacy for milk expression by women during breaks encourages a positive attitude towards the practice of breastfeeding, thereby improving the future health of the community.
Obstetricians can play an active role in promoting, protecting and supporting breastfeeding in different stages of women’s journey with their pregnancy and motherhood. Keeping up with continuous quality education helps to update their knowledge and skills in breastfeeding management. They can work in collaboration with lactation consultants, paediatricians and other health care providers in supporting women, as well as championing breastfeeding policies in hospitals and the workplace. The influence of obstetricians in successful breastfeeding cannot be underestimated.
1. As maternity health care professionals and advocates for women's health , obstetricians are obliged to facilitate women to make informed choices about infant feeding, offer anticipatory guidance, support normal lactation and manage breastfeeding proble.
2. Obstetricians and residents should be adequately trained and continuously educated such that they can provide accurate and unbiased information about breastfeeding.
3. Obstetricians' attitude to their responsibility for safeguarding infant feeding are equally important and are key influences on breastfeeding success. Encouragement from health care providers have been shown to increase breastfeeding initiation.
4. Obstetricians should consult lactation pharmacology resources for up-to-date information on individual medications to avoid women discontinuing breastfeeding unnecessarily, for example, LactMed.
5. Obstetricians should collaborate with lactation consultants and infant care providers to manage breastfeeding problems.
6. Neonatal management protocols can be developed in collaboration with paediatricians to facilitate initiation and sustaining breastfeeding.
7. Obstetricians should support women and be at the forefront to encourage policies which allow women to integrate breastfeeding into their daily lives and the workplace.
For the note of References, please click PDF version.
Views expressed in this article are the author's and do not necessarily reflect the opinion or position of the BFHIHKA.
Editor-in-Chief: Dr Shirley Leung
All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.