Breastfeeding may seem natural. Yet many women find it hard to get off to a good start with breastfeeding.  Sharp decreases in breastfeeding rates around the world reflect this continuing challenge. While most women still choose to breastfeed, many ultimately feel they have no other choice than to stop breastfeeding earlier than anticipated. In the UK, 80 percent of mothers surveyed said they stopped breastfeeding before they wanted to. Many women describe shattered expectations, feelings of deep sadness, guilt, and anger from their breastfeeding experience.  Women do not suddenly stop breastfeeding overnight. They often slog through many days, if not weeks, of gritting their teeth and persevering through two-hourly feedings with sore and cracked nipples, low milk supply, fear that their baby is not gaining enough weight, pumping after breastfeeds, supplementing with expressed breast milk or formula, frequent visits to breastfeeding clinics, and pressure from family to “just give that baby a bottle of formula, it never harmed my babies,” all wrapped up in a bundle of emotional and psychological exhaustion.

Society currently tends to place the responsibility for breastfeeding success on the individual woman and her baby. Yet, there are large cracks in the system. The same system designed to support new mothers and infants also makes it harder for them to do their jobs. We must stand up and say: “No more!” New mothers should not have to shoulder the blame for declining breastfeeding rates. Investigating a far bigger picture of factors involved will reveal what’s really behind the decrease in breastfeeding rates.

Medicalized Birth Practices

A myriad of reasons can lead to early cessation of breastfeeding. But since low milk supply is the leading cause of early breastfeeding drop-off, it is important to discuss the significant impact that labor and birth experience have on a mother’s ability to produce sufficient milk volumes.

Medicalized birth practices are commonplace in almost every hospital. Procedures such as breaking a laboring woman’s waters; continuous monitoring of the fetal heart rate; restricting the woman’s ability to move during labor; and inducing, or speeding up labor with medications, results in slow and/or more painful labor for many women. Understandably, this then leads to a greater need for pain-relieving options. This increased need for analgesia during labor—especially epidurals—has been shown to decrease the rate of spontaneous vaginal birth and therefore increase the rate of assisted birth and the chance of caesarean section.

These medical interventions can lead to a cascade of effects which interrupt normal milk production at a critical point. Immediately after birth, newborns are designed to seek out and latch on the breast. Almost all infants are born with innate reflexes which enable this. Thereafter, the healthy newborn will signal to its mother to frequently feed at the breast. Each time the infant attaches and suckles, they stimulate hormones required to “switch-on” the milk-making cells, enabling the mother to make milk not only for the next feed but to initiate and build milk production sufficiently for the future. It’s a perfect system.

But it doesn’t work when the infant’s reflexes are weakened due to the effects of labor or birth interventions. Babies who are sleepy in their first 12 to 48 hours, from the after-effects of an epidural or traumatic birth, are far less likely to be stimulating the hormones by breastfeeding frequently or effectively. This also means the infant is unlikely to get enough of the early milk, colostrum, leading to greater weight loss and jaundice.

For the mother, the delivery of the placenta signals the hormones to help the milk “come in” (the initial increase in milk volume) between 24 and 72 hours after birth. Yet, for those women who have experienced cesarean section or more difficult births, this is likely to be delayed. Research shows that up to 44 percent of mothers will experience this delay, and those women are more likely to stop breastfeeding by four weeks.  It is easy to see why this might happen; if milk volumes do not increase according to the physiological norm, the baby will begin to lose weight, more than expected in the first few days, leading to formula supplementation and decreased exclusive and frequent breastfeeding. Infants given early formula supplementation are twice as likely to not be fully breastfeeding by the first or second month. And the more formula feeds given in these early days the more likely a mother is to completely stop breastfeeding, as her own milk supply dwindles. 

As lactation consultants we have many tips and tricks up our sleeves to help increase milk supply, but it is vitally important to note that there is a critical time window of the first two to four weeks to produce enough milk for the first six months. After this point, it can be challenging to make any significant increases to maternal milk supply.

Those mothers whose infants are unable to breastfeed well due to the impact of medicalized birth, and who do not receive timely and effective lactation support, unfortunately will likely experience a long-term low milk supply and eventually stop breastfeeding earlier than intended.    

How to Improve Lactation Support

Nurses and midwives play a vital role in providing prenatal education and postnatal support. All healthcare staff should be equipped with evidence-based knowledge and techniques to confidently support mothers who have experienced medicalized birth practices or breastfeeding difficulties.  Providing mothers with support to effectively stimulate the breast if a baby is unable to, such as early, frequent, and effective milk expression is essential to help prevent long-term low milk supply and early breastfeeding drop off. These efforts will also give many more mothers the best chance to achieve their breastfeeding goals.

A Larger Public Health Issue

Of course, many additional factors–societal issues such as educational status, ethnicity, parental leave, and a previous history of trauma from breastfeeding–play an important role in how long mothers breastfeed. However, none of these societal challenges play a large role, if mothers and infants who are at risk of the effects of medicalized birth practices continue to be under recognized and under supported during the short time they have access to postpartum care in hospital.

It is time to stop placing blame on individual mothers for low breastfeeding rates. Instead, acknowledge that this is a much wider public health issue. It is essential to not only examine how healthcare professionals can be better equipped to support mothers to breastfeed, but also recognize the impact ever increasing medicalized birth practices are having on long-term breastfeeding outcomes. To improve breastfeeding rates, we must look to governments, policymakers, and funders to support increased lactation research and breastfeeding education for medical professionals and birthing institutions.