Breastfeeding Promotion in the Prenatal Setting
Breastfeeding promotion in the prenatal setting can significantly influence a mother’s decision to breastfeed. Prenatal encouragement increases breastfeeding rates and can identify potential problem areas. The Academy of Breastfeeding Medicine Protocol Committee offers a guideline to discuss breastfeeding at each prenatal visit.11 See ABM Clinical Protocol #5 Peripartum Breastfeeding Management for the Healthy Mother and Infant at Term, Revision 2013.
Anticipatory Guidance: Key Points
Healthcare providers who interact with pregnant women in the prenatal period play an important role in laying the foundation for breastfeeding success. Discussions about breastfeeding goals and expectations throughout the prenatal period will help the healthcare provider and the expectant mother work together to identify her support system and the individuals who will have an impact on her success.
Lack of support from a significant other has been identified as the most important factor for those who chose to formula feed.12
Knowing the mother's family and cultural background can assist the clinician in identifying potential barriers. The patient's support person, and whoever accompanies her to office visits, should be included in breastfeeding promotion efforts, since they are likely to be important influencers in her decision to breastfeed.12
Mother’s Intentions and Attitudes Toward Breastfeeding
Counsel all pregnant women about their infant feeding decisions, even those who have other children.
One of the techniques developed to counsel women regarding their infant feeding options is the Best Start Three-Step Counseling Strategy© by Best Start Social Marketing. This counseling strategy is evidence-based and designed to address the barriers to breastfeeding. This technique allows for health care providers to openly discuss questions and concerns with patients.
The three steps of the Best Start Three-Step Counseling Strategy include:
- Step 1: Ask an open-ended question.
This encourages open dialogue about breastfeeding by beginning with open-ended questions. This will elicit a mother’s particular barriers to choosing breastfeeding and allow you to hone in on her personal issues. It is an efficient way to direct your educational efforts toward her concerns.
“What have you heard about breastfeeding?”
“What concerns do you have about breastfeeding?”
- Step 2: Affirm her concerns.
This step is critical as it will help the patient realize that you are listening to her. It normalizes any concerns the patient may have; it lets her know you don’t consider her concerns silly or stupid; and importantly, this helps her develop a relationship with you.
“You know, I hear that worry from lots of women... good for you to mention that.”
“Many women wonder if their diet has to be really good to breastfeed.”
- Step 3. Provide targeted education directed at her specific concerns.
Address concerns and dispel misconceptions at each visit.
“Did you know that your breast works to make quality milk even when your diet is not so great?”
“There are lots of ways to feed your baby when you are separated – here’s a pamphlet about breastfeeding after returning to work.” 13
The Academy of Breastfeeding Medicine's Protocol #19: Breastfeeding Promotion in the Prenatal Setting recommends that the following trimester strategies be implemented in concordance with the three steps of the Best Start Three-Step Counseling Strategy noted above:
- The First Trimester
- Incorporate and educate partners, parents, and friends about the benefits of breastfeeding for mothers and babies.
- Assess baseline knowledge about breastfeeding.
- Promote benefits of breastfeeding for mother and baby.
- Address known common barriers such as lack of self-confidence, embarrassment, time and social constraints, dietary and health concerns, lack of social support, employment and child care concerns, and fear of pain.
- Emphasize the importance of exclusively breastfeeding for six months.
- Continue to ask open-ended questions.
- Encourage women to find out if they qualify for WIC and enroll if eligible. Women can participate in WIC as soon as they learn they are pregnant, even before they have their first OB visit.
- The Second Trimester
- Encourage women to identify breastfeeding role models by talking with family, friends, and colleagues who have breastfed successfully.
- Discuss the link between labor and delivery experience and successful breastfeeding, including non-pharmacologic and pharmacologic interventions for pain management in labor.
- Discuss breastfeeding basics such as the importance of exclusive breastfeeding and supply/demand, feeding on demand, frequency of feedings, feeding cues, how to know an infant is getting enough to eat, avoiding artificial nipples until the infant is nursing well, and the importance of a good latch.
- The mother working outside the home should be encouraged to begin thinking about if and when she will return to work after the baby is born. If she is planning on returning to work, encourage the woman to consider what facilities are available for pumping and storage of breastmilk, how much time she will take for maternity leave, and what company policies and legislation are available to support her.
- Recommend attending a prenatal breastfeeding program for the patient and her partner in addition to office education.
- Encourage participation in a breastfeeding peer support group. Provide a list of local educational options and breastfeeding resources for patients (e.g., www.zipmilk.org).
- The Third Trimester
- Discuss what will happen in the delivery room under normal conditions (covered below in Maternity section that follows this section).
- Encourage the creation of a birth plan that includes the importance of practices that promote breastfeeding success.
- Review the physiology of breastfeeding initiation and how supplementation can inhibit development of the mother’s milk supply.
- Discuss the variety of positions that mothers use when breastfeeding their newborns:
- Side lying or laid back/biological nurturing position
- Cradle hold, across the lap or cross cradle
- Clutch hold or football hold
Each mother needs to find a position or positions that work for her. It is important for mothers to be in a comfortable position during breastfeeding. In the first postpartum days, laid back or side lying may be the easiest. After a cesarean section, the clutch hold may be most comfortable.
Demonstrate breastfeeding mechanics such as positioning the newborn at the breast. Use a doll to explain various positions.
- Discuss the importance of early skin-to-skin contact (covered below in Maternity section that follows this section).
- Establish the expectation that the first few feedings will be small (covered below in Maternity section that follows this section).
- Discuss the importance of hand expression. Hand expression relieves engorgement and works better than a pump initially; it may help with latch in the first days. View a demonstration of hand expression.
- Discuss the available breastfeeding resources in the hospital.
- Recommend the purchase of properly fitting nursing bras.
- Encourage another visit to a breastfeeding support group as the mother’s interest and goals of attending may be different than when she attended early in the pregnancy.
- Recommend the mother identify a pediatric provider that supports breastfeeding.
- Suggest that she discuss plans for infant health care and breastfeeding support with her pediatric care provider.
Medications and Breastfeeding During the Prenatal Period
Check all medications for safety during lactation. Many medications are safe while breastfeeding, and the risk of the medication compared to the risk of not breastfeeding should be evaluated and discussed with the patient When necessary, identify alternative medications that are safe while breastfeeding. References to use when assessing medication compatibility with breastfeeding include: LactMed and Infant Risk Center.
Every effort should be made to make sure that any adjustments to medications made during pregnancy include choices that are also compatible with breastfeeding.
- Because no information is available on the use of the anti-hypertensive Lisinopril during breastfeeding, an alternate drug may be preferred, especially while nursing a newborn or preterm infant. Alternatives include captopril or Enalapril or a beta-blocker such as Labetalol, if appropriate for the patient’s condition.
- There are better alternatives to the anti-depressant Venlafaxine (Effexor™) in pregnancy and breastfeeding; better alternatives are Sertraline (Zoloft™) and Paroxetine (Paxil™). Read more.
Other Substances and Breastfeeding:
Overall, medical providers advise against using marijuana while breastfeeding. The active component of marijuana, Tetrahydrocannabinol (THC), is excreted into breastmilk. THC is fat soluble and remains in the tissues for 2-3 weeks.13 In October 2017 ACOG published Committee on Obstetric Practice paper, which stated “There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.”14
The Academy of Breastfeeding Medicine also provides guidelines for breastfeeding and Substance Use or Substance Use Disorder. The publication, revised in 2015, offers more detailed information on how to advise mothers on breastfeeding if they use marijuana. 15, 46.
Smoking is not a contraindication for breastfeeding; however, smokers are less likely to breastfeed. Smoking interferes with milk ejection reflex (let-down) and milk yield. Avoidance of smoking for two hours before a feeding may improve let down and minimize amount of nicotine in milk.16
Methadone and Buprenorphine
In August 2017, The American College of Obstetricians and Gynecologists published a Committee Opinion in collaboration with The American Society of Addiction Medicine. The document states that “breastfeeding should be encouraged in women who are stable on their opioid agonist, who are not using illicit drugs, and who have no other contraindications, such as HIV infection. Women should be counseled about the need to suspend breastfeeding in the event of a relapse.” 17 The American Academy of Pediatrics recommends breastfeeding for women taking methadone and buprenorphine regardless of maternal dose, as transfer of these medications into breast milk is minimal.18