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Nursing confidential

Breastfeeding can be one of the biggest challenges of new motherhood. Now 7,000 Today’s Parent readers tell us why

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Any mother who gives birth in the Western world gets the message that she should breastfeed her baby. American health promoters recently upped the ante with a new publicity campaign designed to make mothers aware of the risks of not breastfeeding. One ad likens the risk to riding a mechanical bull when pregnant. It’s an eye-catching message — if you assume that a woman’s attitude is the critical factor determining whether she’ll succeed or fail at breastfeeding.

We at Today’s Parent have long felt that pointing fingers at mothers is not only unfair, it doesn’t address the real problems in breastfeeding. Readers and professionals we trust have told us for years that unsolved problems, bad advice and lack of support were the true culprits. Now we’ve got data to prove it.

In May, Today’s Parent undertook a large-scale survey on breastfeeding. We wanted to find out what determines whether a mother is able to breastfeed successfully. We asked what problems women experienced, who they went to for help, what information and support they received and what they thought of the help they got.

The first thing we learned was how passionate mothers are about breastfeeding (as if we didn’t already know). Over 7,000 answered the survey! Some 400 followed up with emails. Our survey is not a random sample; it’s a self-selected but very large group of mothers, mostly well informed and committed, who nursed their babies longer than average — breastfeeding enthusiasts, you might say.

However, some faced enormous challenges. Their insights and experiences speak volumes to anyone who cares about breastfeeding.

We looked at outcomes in several ways: duration of breastfeeding, whether a woman breastfed as long as she wanted to, and her satisfaction with the experience.

Our sample includes numerous successful breastfeeders. They were less than half as likely to stop nursing before three months as mothers polled in the 2003 Toronto Perinatal and Child Health Survey (10.5% vs. 23.4%). Also, more moms who answered our poll breastfed longer than 12 months (37.5% vs. 25.6% in the Toronto survey).

However, if we look only at women who were not currently breastfeeding, almost one-third said they stopped before they wanted to. Plus, our survey asked mothers to report about their most recent baby, which in many cases was not the first. Some women told us that, though they had succeeded with baby two or three (the experience reflected in our numbers), they had not succeeded with baby number one. Stopping earlier than intended is clearly a significant problem, and most likely even more prevalent than our data indicate.
Challenges: Almost universal

Most mothers hope nursing will feel natural and come easily. Sometimes it does. “Breastfeeding was wonderful for me,” wrote Melissa Canady of Nanticoke, Ont. “The first time I nursed my baby, shortly after he was born, he latched right on and knew what to do. I had a nearly perfect experience with very little difficulty and I feel lucky.” Unfortunately, she’s in a small minority: Only one mother in 10 reported problem-free breastfeeding.

These numbers suggest that everyone, particularly expectant mothers and fathers, needs to understand that breastfeeding challenges are, well, pretty normal — and that women need skilful technical help and moral support to solve them, if we want more mothers to nurse for longer. (Current guidelines from Health Canada, the Canadian Paediatric Society and the World Health Organization recommend exclusive breastfeeding for six months.)

In fact, some respondents were livid that no one had forewarned them about breastfeeding problems. “Any doctor or nurse I had contact with during my pregnancy touted the benefits of breastfeeding and would supply me with endless resources cheerleading its cause,” says Kelly Hiltz from Halifax. “No one informed me of the realities of nursing. I was absolutely shocked at how hard it was.” Lorna Hargrove of Rothesay, NB, agrees: “It’s a taboo subject that no one discusses.” Obviously, those in health promotion have a tricky line to walk. They don’t want to discourage breastfeeding by making it sound too hard, but they need to help women understand that difficulties aren’t unusual — or insurmountable.

Which brings us to the the good news: Our survey shows clearly that breastfeeding problems can be overcome. Ninety percent of our sample faced at least one problem; three out of five struggled with sore nipples, and about the same number complained of latch problems. (Experts say a poor latch is the prime fixable source of nipple pain and tissue damage.) Yet, of the women not currently breastfeeding, the average duration of their longest breastfeeding experience was 11.5 months.

Sore nipples, for example, one of the most common problems, was not statistically associated with early weaning, although numerous mothers told us in wince-inducing detail just how hard it is to nurse when you’re in agony.

Kim Girolimetto’s early breastfeeding experience was fraught with mishaps, starting with induced labour which took three days to get going, and including instruction from an “incompetent nurse who told me my daughter was latched when she wasn’t.” Then the Toronto mother was told it was crucial to feed her daughter at least every two hours because she was jaundiced, something her family doctor later said was not necessary. Trouble was, Girolimetto had a very sleepy baby. “We would spend up to an hour desperately trying to wake her enough to feed her, have another droopy and exhausted feeding, let her sleep for less than an hour, and start the whole process again,” she explains. “Between my inexperience and my daughter’s and my sleepiness, we couldn’t get a good latch.”

Here’s the wild part. In spite of all this, and in spite of struggling with her baby’s low weight gain for five months, this mother went on to breastfeed for a year. So clearly, some women are able to overcome problems, lack of support and bad advice, and still breastfeed successfully.
Problems and early weaning

Our data can’t establish the exact extent to which problems cause women to stop breastfeeding before they want to. But three difficulties were roughly twice as prevalent in women who stopped early: low milk supply, low baby weight gain and a baby who seemed uninterested in nursing or nursed ineffectively.

But, once again, these numbers reveal that a fair number of mothers were able to overcome these problems. So who helped them?

Overall, 91 percent of mothers got breastfeeding help and support from at least one health professional and, clearly, nurses are on the front lines.

Eighty-six percent of our respondents rated professional help as good or excellent; 79 percent said the same thing about the support they got from family and friends. However, what’s troubling is, while almost all breastfeeding starts out in hospitals, one in four of our respondents got no advice or support from hospital nurses. And hospital nurses, who were by far the most frequent sources of advice and support, did not rate as highly for accuracy and helpfulness as other health professionals, particularly specialized practitioners such as breastfeeding clinic staff, lactation consultants, midwives, doulas and even volunteer counsellors such those from La Leche League.

These results show most mothers feel they are getting accurate information and good help, though the discrepancies between accuracy and helpfulness are striking. However, the relatively low ranking of hospital nurses suggests a problem with the quality and consistency of breastfeeding support in hospitals. Since many moms deal with several maternity ward nurses, we gave them a chance to rate the accuracy and helpfulness of more than one nurse, and “other hospital nurse” got the lowest rating. Thirteen percent rated the advice of a second hospital nurse unhelpful or harmful (with public health nurses and lactation consultants, it was only 4%).

To be fair, hospital nurses have a tough job. They have numerous responsibilities other than breastfeeding, they don’t see their clients for very long (often the mothers go home before their milk comes in), and problems are not always readily apparent on the first or second day. However, that doesn’t excuse some of the appalling stories we heard. Melinda Lampitt of Mississauga, Ont., had her hand slapped by a nurse who felt she was holding it too close to the baby’s mouth. “I will never forget how helpless I felt at that moment…like I was failing my baby,” she said. Michelle Puffer of Maple Ridge, BC, said that five out of the seven nurses she saw during her nine-day hospital stay would, upon entering, immediately grill her about whether or not she had a good latch, without taking time to read the chart to learn that she did. Two of these nurses wanted to know about the state of her milk and reached into her nightgown, grabbed her breast and squeezed. “This is my third child. I know when I’ve got a good latch. I know if my milk is coming in properly.” She found this treatment terribly invasive and burst into tears a few times.

Although we are highlighting poor support and advice because of the role it can play in breastfeeding breakdown, we should emphasize that a large majority of moms rated their overall support from health professionals as either excellent (44%) or good (42%). Mary Furlong doubts she could have breastfed her daughter, born three months premature, without the help of the nurses at St. Joseph’s Healthcare in Hamilton. “You can imagine how difficult it is to have such a tiny infant learn to breastfeed,” she says. “The NICU has several nurses who are also lactation consultants, but they all seemed to know the tricks. We got to take her home four weeks earlier than expected largely because of the patience, encouragement and excellent breastfeeding help from those nurses.”
Another obstacle some mothers faced was inconsistency in the information they were given. In our survey, conflicting advice was reported more often by women with certain problems: 17% whose babies had low weight gain complained of somewhat or very inconsistent advice, as did 150f those with low milk supply. (The number was only 6% among moms who reported no breastfeeding problems.)

Andrea Maenza of Courtice, Ont., was told by one nurse that she had to pump at every feeding, including the middle of the night. However, she was exhausted. The other nurses told her to sleep, so she didn’t pump that night. “Then the other nurse would come in and get mad at me because I hadn’t pumped,” Maenza says. Kim Girolimetto had a similar experience. “Four different nurses would say four completely different things. I knew one of them was probably right, but as a first-time mom, how was I supposed to know which one?”

Although this kind of inconsistency was the exception in our sample, mothers who said they stopped breastfeeding before they wanted to (as well as those who nursed only one to four months) were more likely to say the information they received was fairly or very inconsistent than those who stopped by choice — 17% and 9% respectively.

But the most telling association revealed itself when we looked at the relationship between quality of professional support and outcomes. Of the mothers who breastfed one to four months, 27% rated professional support as poor or fair, compared to only 110f mothers who nursed seven to 12 months. However, it’s only fair to note that even mothers who stopped early gave mostly good ratings to professional support; almost a third said it was excellent. So while inadequate professional support clearly plays a role in breastfeeding breakdown, it’s not the only factor.

We were surprised that almost one in three mothers reported their babies had been given formula in the hospital, and even more surprised to hear experts tell us this is probably lower than average. Breastfeeding proponents have argued for years that giving babies formula in hospital lowers the chance of breastfeeding success. Our data can’t establish cause and effect but, clearly, mothers who weaned early were much more likely to say their babies got formula or sugar water (seldom used these days) in hospital.

The baby factor

One of the least talked-about factors in breastfeeding breakdown may be the baby himself. Debbie Leicht of St. Brieux, Sask., had twins. One nursed like a pro while the other didn’t seem to know how to suck at first and lagged behind his brother in weight gain. After three months of trying, including bottle-feeding him breastmilk, she switched him to formula while the other twin continued to breastfeed. Almost one in four mothers had a baby who was fussy at the breast or in between feedings. Several told us how distressing this was. “My first son breastfed fairly well for the first two months, supplemented with bottles as well,” said Lisa Sansom of Kingston, Ont. “Around eight weeks, he started to fuss incredibly at the breast. After five minutes of nursing, he would break off, do this weird head-shaking thing, back and forth across the nipple, and he’d scream.” She persisted for another 10 weeks, but ultimately stopped after an emergency appendectomy.
For the most part, our survey validates what the best breastfeeding people have said for years.

Everyone — health professionals, friends and family, parenting media, health policy-makers — must work harder to support mothers. In particular, more training is needed for health professionals in how to advise and support breastfeeding moms. The Baby-Friendly Hospital Initiative is a designation created by the World Health Organization for hospitals that follow a protocol known to enhance breastfeeding. Currently, Canada has only four Baby-Friendly hospitals (find out more at breastfeedingcanada.ca). Governments could push more hospitals in this direction. After all, we publish school test scores as an accountability measure. Why not force hospitals to publish their rates of formula supplementation, breastfeeding success and client satisfaction?

For mothers — and fathers too — there are three big lessons. First, breastfeeding problems are common and, arguably, should be anticipated. Second, most can be solved (or prevented!) with timely, competent advice and support. Third, see a breastfeeding specialist if you want to solve your problems. Several emailers vowed that next time they would seek specialist help much more quickly.

Finally, mothers and their partners don’t need any more pressure to breastfeed. Several respondents — including breastfeeding enthusiasts — complained about this. The vast majority of Canadian mothers start out breastfeeding (in Toronto, it was 94 0n 2003). They already know it’s important. If we want more mothers to nurse longer, they don’t need rules, slogans and pressure, but rather compassion, understanding and better help.

Who Answered Our Survey

• Number of respondents: 7,378
• Percentage currently breastfeeding: 45%
• Percentage not currently breastfeeding but did within last three years: 55%
• Percentage who have breastfed one child: 53%
• Percentage who have breastfed more than one child: 46%