As World Breastfeeding Week continues, the role of the midwife in promoting and facilitating breastfeeding for new mothers is examined. Midwifery clients and their babies exceed national breastfeeding rates compared to the general population and our authors today, Jill Breen, Jeanette McCulloch and Lauren Korfine take a look at some of the reasons behind this boost. - Sharon Muza, Community Manager, Science & Sensibility

By, Jill Breen, CPM, President, Midwives Alliance (MANA), Jeanette McCulloch, IBCLC, Board Member, Citizens for Midwifery and Lauren Korfine, PhD, Citizens for Midwifery

© Luna Maya Birth Center (Cris Alonso)

As we honor World Breastfeeding Week, those of us who deliver or receive midwifery care have much to celebrate. In every study we can identify, midwifery care increases the likelihood that a woman will initiate breastfeeding (Hatem, Sandall, Devane, Soltani & Gates, 2008). Even with national breastfeeding initiation rates at a recent high of 77% (Centers for Disease Control and Prevention [CDC], 2013), depending on the setting, the rates of initiation and ongoing breastfeeding for women under the care of midwives well exceed national averages.

Preliminary data from a sample of more than 24,000 home and birth center births attended by midwives showed remarkable breastfeeding rates. Less than one percent of all mothers never breastfed. Eighty-five percent were exclusively breastfeeding through to the final postpartum visit, which is typically at the six week mark. A full 97% were at least partially breastfeeding at six weeks (Cheyney, 2012).

Benchmarking data that tracks breastfeeding initiation rates for families receiving care from certified midwives and certified nurse midwives showed significantly higher rates than those whose care was provided by an OB: 78.6% as compared to 51% at the time the report was compiled (American College of Nurse Midwives [ACNM], 2012).

What is it about midwifery care that helps women achieve rates of breastfeeding that meet or exceed the Healthy People 2020 objectives. And most importantly, how can we replicate these important factors in all settings, and with all types of providers?

Education

Research tells us that prenatal breastfeeding education significantly impacts breastfeeding success, either one-on-one or in a group (de Oliveira, Camacho & Tedstone, 2001). Midwifery care typically includes a strong prenatal education component, which includes discussions of infant feeding. CenteringPregnancy®, relatively new model of midwife-led prenatal care in a group setting, including breastfeeding education, has been highly successful (ACNM, 2012) and could be replicated in many settings. In addition, one key aspect of the homebirth model - significant one-on-one time spent prenatally - ensures a woman's breastfeeding goals and preferences are aligned with education she receives before the birth (Midwives Alliance of North America [MANA], 2012).

Providing high-quality breastfeeding education as a regular, expected part of prenatal care, (either individually or in a group) - as it is with midwifery care - could significantly increase breastfeeding success.

Birth practices

A substantial body of research illustrates that, without a doubt, birth practices can greatly impact breastfeeding success. In their second edition book on the connections between birth and breastfeeding, Linda Smith and Mary Kroeger (2009) outline a number of birth practices that impact a mother's ability to reach her breastfeeding goals. According to Smith & Kroeger:

"Solid scientific evidence shows that minimizing interventions in birth and policies that preserve normalcy are associated with faster, easier births; healthier, more active and alert mothers and newborns; and mother-baby pairs physiologically optimally ready to breastfeed." (p. 24)

A growing body of research shows that skilled midwifery care, including home and birth center birth, is as safe for babies as hospital settings and results in lower interventions for mothers in low risk births (Vedam, Schummers, Stoll & Fulton, 2012). The significance of the lower intervention rate appears to be about more than the health and wellbeing of the mother, or her birth satisfaction. A mother-baby pair with fewer birth interventions appear to be more likely to establish successful breastfeeding. This makes reducing birth interventions an essential public health goal.

Reduced interventions are possible in all settings with all providers, not just under the care of midwives. The CIMS model of mother-friendly care outlines clear steps a birthing facility can take to ensure mother-friendly (i.e., low-intervention) maternity care (Coalition for Improving Maternity Services, 1996). These steps would not only improve birth outcomes and reduce costs, but would also likely increase breastfeeding rates.

Ongoing support

With a drop of more than 25 percentage points between breastfeeding initiation and those breastfeeding at six months in the United States (CDC, 2013), part of what families lack is ongoing breastfeeding support. Notably, the CDC Breastfeeding Report Card included two new indicators this year - rates of skin-to-skin contact after a vaginal birth and rooming in at least 23 hours of a postpartum hospital stay (CDC, 2013). These indicators were chosen specifically because of the positive impact these practices have on breastfeeding rates.

Only 54% of babies born in the US are skin-to-skin in the first hour after a vaginal birth, although up from 41% in 2007 (CDC, 2013). This is in sharp contrast to what the overwhelming majority of mothers experience in the care of midwives. As described in the Midwives Alliance position paper on homebirth;

"Nursing the newborn in the first hours is undisturbed in the homebirth setting. Motherbaby closeness, motivation, encouragement, and knowledgeable guidance contribute to high success rates of breast-feeding for home birth families." (MANA, 2012)

Typical breastfeeding support provided by a midwife extends well past the first 24 hours of life. Although we are unaware of research that supports this, anecdotal evidence suggests that the continuity a midwife provides in the first six weeks plays a large role. For example, one midwife describes her approach: "After birth we wait for self attachment, encourage skin to skin. But when a woman has trouble, I always start my conversation with, 'What is it you want? What is your goal in breastfeeding?'" says Treesa Mclean, LM, CPM, a midwife based in California. "Then we make 24 hour plans. My role is listening to the mom, making a plan they like and meeting them where they are." Midwifery care often extends past the typical 3 day and 6 week visit, with additional follow-up when needed to ensure breastfeeding is well-established.

These practices - support in the early days through basic practices like skin-to-skin contact, maintaining proximity between a newborn and nursing parent, and providing a continuity of breastfeeding support - are all enjoyed by families who employ the care of a midwife. However, there is nothing in the midwifery model of care that is unique to these practices. Any provider - from home birth providers to hospital based OBs - can employ all or nearly all of these strategies, except in unique circumstances. We hope that all providers can learn from and replicate the practices of midwifery, with the goal of ensuring improved breastfeeding outcomes for all families.

References

American College of Nurse-Midwives [ACNM]. (2012). Midwifery: Evidence-Based Practice. A Summary of Research on Midwifery Practice in the United States. Retrieved from http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002128/Midwifery%20Evidence-based%20Practice%20Issue%20Brief%20FINALMAY%202012.pdf.

Centers for Disease Control and Prevention [CDC]. (2013). Breastfeeding Report Card: United States/ 2013. Retrieved from http://www.cdc.gov/breastfeeding/pdf/2013BreastfeedingReportCard.pdf.

Cheyney, M. (2012). "Research updates." Conference presentation at the 2012 Annual Conference of the the Midwives Alliance of North America.

Coalition for Improving Maternity Services. (1996). "Mother-Friendly Childbirth Initiative." Retrieved from http://www.motherfriendly.org/MFCI.

de Oliveira, M. I. C., Camacho, L. A. B., & Tedstone, A. E. (2001). Extending breastfeeding duration through primary care: A systematic review of prenatal and postnatal interventions. J Human Lact17(4):326-343.

Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S. (2008). Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 2008(4). doi:10.1002/14651858.CD004667.pub2.

Midwives Alliance of North America [MANA]. (2012). Homebirth Position Paper.Retrieved from http://mana.org/sites/default/files/MANAHomebirthPositionPaper.pdf.

Smith, L. J., & Kroeger, M. (2009). Impact of Birthing Practices on Breastfeeding, 2nd ed. Sudbury, MA: Jones and Bartlett Publishers.

Vedam, S., Schummers, L., Stoll, K., & Fulton, C. (2012). Home birth: An annotated guide to the literature. Retrieved from http://mana.org/research/homebirth-safety.

About the Authors

© Jill Breen

Jill Breen, CPM, has been a homebirth midwife for over 35 years. She is the mother of 6 homeborn children and has 7 grandchildren, all born into the hands of midwives, including her own! She is the president of the Midwives Alliance of North America (www.mana.org).

© Lauren Korfine

Lauren Korfine, PhD is a mother of three, and she works as a doula, community educator, and consumer advocate. Prior to having children, she was a lecturer in psychology and women's studies. She is a founding member of BirthNet of the Finger Lakes, a consumer advocacy and education organization. Lauren analyzes research and writes for Citizens for Midwifery. She received her degrees from Cornell and Harvard Universities, but her education from her three children. She lives with her family in Ithaca, New York.

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, is the co-founder of BirthSwell and a true believer in the power of communications to create change. She is a board member at Citizens for Midwifery and the mother of two children, born with the love and support of midwives.

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