Health Care Issues: Birthing Practices & Breastfeeding
Pregnancy, labour, birth, and breastfeeding are normal and healthy processes. The mother and baby constitute an integral unit during pregnancy, birth, and infancy (referred to herein as the “MotherBaby”) and should be treated as such, as the care of one significantly impacts the care of the other.
Obstetrical practices can negatively impact a woman’s ability to breastfeed. Birth and breastfeeding cannot be separated—they are part of the motherbaby continuum–and the way birth proceeds can have a major impact on the way breastfeeding will proceed. Any procedure that interrupts the mother’s physiological systems or interferes with her self-esteem can be highly detrimental to breastfeeding, including drugs used during labour and birth, disrespectful care, suctioning the baby at birth, early cord clamping, and separation of motherbaby after birth.
The International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal Maternity Care promotes a motherbaby model of care that will transform birth and breastfeeding practices around the world. The IMBCI focuses on facilitating normal birth, avoiding unnecessary interventions, and supporting breastfeeding.
An optimal MotherBaby maternity service has written policies, implemented in education and practice, requiring that its health care providers:
Step 1 Treat every woman with respect and dignity.
Step 2 Possess and routinely apply midwifery knowledge and skills that optimize the normal physiology of birth and breastfeeding.
Step 3 Inform the mother of the benefits of continuous support during labour and birth, and affirm her right to receive such support from companions of her choice.
Step 4 Provide drug-free comfort and pain relief methods during labour, explaining their benefits for facilitating normal birth.
Step 5 Provide evidence-based practices proven to be beneficial.
Step 6 Avoid potentially harmful procedures and practices.
Step 7 Implement measures that enhance wellness and prevent illness and emergencies.
Step 8 Provide access to evidence-based skilled emergency treatment.
Step 9 Provide a continuum of collaborative care with all relevant health care providers, institutions, and organizations.
Step 10 Strive to achieve the BFHI 10 Steps to Successful Breastfeeding.
The IMBCI acknowledges the great variation in resources and access to care around the world. The challenge for the 21st century is to increase access to skilled caregivers and emergency care where these are lacking while decreasing the overuse of unnecessary medical interventions, increasing understanding of normal birth and breastfeeding, and improving quality of care in all countries.
Baby-friendly (H)ospital Initiative(BFHI) added the Mother-friendly Care new optional Global Criteria and questions have been added to ensure that practices are in place for mother-friendly labour and delivery. These practices are important, in their own right, for the physical and psychological health of the mothers themselves, and also have been shown to enhance their infants’ start in life, including breastfeeding. Many countries have explored options for including mother-friendly criteria within the Initiative, in some cases re-terming their national initiatives as “mother and baby friendly”. Other countries have adopted full “mother-friendly” initiatives. New self- appraisal and assessment questions on this topic offer a way for countries that have not done so already to add a component focused on the key “mother-friendly” criteria needed for an optimal “continuum of care” for both mother and child from the antenatal to postpartum period.
The 5 steps of the Global Criteria include:
- Encourage women to have companions of their choice to provide continuous physical and/or emotional support during labour and birth, if desired.
- Allow women to drink and eat light foods during labour, if desired.
- Encourage women to consider the use of non-drug methods of pain relief unless analgesic or anaesthetic drugs are necessary because of complications, respecting the personal preferences of the women
- Encourage women to walk and move about during labour, if desired, and assume positions of their choice while giving birth, unless a restriction is specifically required for a complication and the reason is explained to the mother.
- Care that does not involve invasive procedures such as rupture of the membranes, episiotomies, acceleration or induction of labour, instrumental deliveries, or cesarean sections unless specifically required for a complication and the reason is explained to the mother.
Together with the guidelines set by the IMBCI and BFHI Global Criteria there is significant evidence based research to support breastfeeding through improving birth practices.
The following provides a brief summary of what the scientific evidence shows regarding the way birthing practices and interventions influence both mother and baby’s ability to breastfeed. For more information, please see the references:
Importance of a Labor Support Person
• Evidence shows that continuous female labor support reduces the need for many labor interventions, especially for first time mothers.
• The resulting interventions, such as epidural anesthesia, cesearan section and hormones often delay the initiation of breastfeeding.
• Most hospitals in resource poor countries continue to prevent a labor support person from accompanying a laboring woman despite the evidence of the benefits to mother and baby and cost effectiveness.
Benefits of giving Oral Fluids and Food during Labor
• Withholding food and drink during labor, a common practice in both the developing and developed world, is an outdated practice that has been shown to negatively affect birth outcomes.
Side effects of Labor Pain Medication
• Epidural anesthesia can lead to poor progress of labor, a longer second stage, a lower rate of spontaneous vaginal delivery (a higher rate of the delivery with instruments such as forceps and a vacuum), an increase in maternal fever, and an increase of newborns evaluated and treated for sepsis.
• Evidence also shows that both epidural and narcotic analgesia adversely impacts breastfeeding.
• Drugs such as Demerol (meperidine) given during labor leads to central nervous system depression in the fetus and newborn and negatively impacts breastfeeding.
Potential harm of Cesarean Section and Assisted Delivery
• New evidence outlines a clear link between cesarean sections and a later initiation, later onset of lactogenesis, and shorter duration of breastfeeding.
• Globally, the rate of cesarean sections is increasing yearly and has reached astounding levels in some South American countries.
• Delivery with a vacuum or forceps may have a direct impact on the anatomy and physiology of the newborns head, jaw and cranial nerves, hindering the ability of the baby to properly suckle
The Values of Immediate Skin-to-Skin Contact directly after birth
• A baby left on its mother’s abdomen has inborn behaviors that lead it to the breast to feed.
• Interventions during childbirth and immediately after birth can interfere with bonding, mothering and optimal initiation of breastfeeding. This is especially relevant in cases of cesarean sections.
• Kangaroo care (prolonged skin-to-skin contact) for premature infants stabilizes temperature, heart rate, respiratory rate, reduces crying, and supports breastfeeding for babies who would, if
places in an incubator, be formula fed.
Ability for Mom to chose any Position during Labor and Delivery
• Evidence shows that the ability of a woman to move around freely during the first stage of labor and take an upright (including squatting) position during the second stage of labor leads to less interventions, a faster delivery, fewer episiotomies, and therefore a mother and child more able to initiate breastfeeding.
• There is no evidence that continuous electronic fetal monitoring improves maternal outcomes, and it generally requires that the mother stays in bed, therefore disallowing the laboring woman to walk or take the position of her choice for an easier labor and delivery.
• Mother and baby and cost effectiveness.
The dangers of IV Hydration
• Some commonly used IV solutions can lead to electrolyte imbalances, jaundice, and other problems in the newborn; conditions which may lead to prolonged separation of the mother and baby, and therefore would effect the initiation and continuation of breastfeeding.
Potential harm of Episiotomies
• Episiotomies can have a negative impact on the mother’s comfort and therefore her ability to initiate and continue breastfeeding. Recent evidence supports the idea that episiotomies actually increase the rate of tarring that surgical cuts heal more slowly than does a natural tare of the perineum.
Detrimental effects of stress and fear
• Oxytocin, the primary hormone involved in both birth and breastfeeding is inhibited by adrenaline produced by the mother when she is fearful and anxious during labor.
• Labor events, such as episiotomies, surgical interventions, and multiple procedures are stressful to the mother and are associated with less frequent suckling and later onset of lactation.
• Alternative (non pharmacologic) pain relief methods such as offering the mother a hot bath or shower and giving her a massage can be helpful and facilitate an easier birth, which can in turn lead to a faster initiation of breastfeeding.
• Many pain medications actually block the body’s natural endorphins that the body releases to block pain close to delivery.