• Step 3 of the Ten Steps to Successful Breastfeeding states:
Inform all pregnant women of the benefits and management of breastfeeding. • In many cultures, women assume that they will breastfeed. In other cultures, where breast
milk substitutes are widely advertised and promoted, most women decide whether or not to breastfeed before their baby is born. It is important for health workers to educate women about breastfeeding as early as possible and to identify mothers and babies who may be at risk of breastfeeding difficulties.
• In order to make an informed decision about feeding her baby a woman needs:
- Information that is accurate and factual about the importance of breastfeeding and the risks of replacement feeding - not the health worker’s personal opinion or marketing information from a formula company.
- Understanding of the information in her individual situation – this means giving information in words that are suitable for the woman and discussing the
information in the context of her situation.
- Confidence, which means building the woman’s confidence in her ability to exclusively breastfeed. If she is not breastfeeding, she needs to be confident that she can find a replacement feeding method that is as safe as possible in her situation.
- Support to carry out her feeding decision. This includes support to successfully feed her baby and to overcome any difficulties.
• The woman needs to believe that she can carry out her decision. It is not enough for the health worker to think that she or he has provided sufficient information or support; the health worker needs to check with the woman that her information and support needs are met.
Fatima and Miriam are at the antenatal clinic. While they are waiting, there is a nurse talking with a group of pregnant women about feeding their baby. Fatima and Miriam listen to the talk.
7 Use other names as culturally appropriate.
Group talk during pregnancy
Ask: What do you think are the main points to include in a group talk about feeding a baby?
Wait for participants to respond. Give an antenatal group talk
• During a group talk to pregnant women, pregnant women in the group who breastfed before can be asked to discuss their positive experiences and identify causes why others had problems and how to prevent them.
• The pregnant women can be given more information on managing breastfeeding such as by using dolls to show how to position the infant for breastfeeding.
- Facilitator presents the following information as if it was a talk to a group of pregnant
women.
Why breastfeeding is important
• Breastfeeding is important to children, to mothers and to families. Breastfeeding protects infant’s health. Children who are not breastfed are more likely to be:
- Ill or to die from infections such as diarrhoea and gastrointestinal infections, and chest infections.
- Underweight and not grow well, if they live in poor circumstances.
- Overweight and to have later heart problems, if they live in rich circumstances. • Breastfeeding is important to mothers. Women who do not breastfeed are more likely:
- To develop anaemia and to retain fat deposited during pregnancy, which may result in later obesity.
- To become pregnant soon after the baby’s birth. - To develop breast cancer.
- To have hip fractures in older age. • In addition:
- Breast milk is readily available. There is nothing to buy and it needs no preparation or storage.
- Breastfeeding is simple, with no equipment or preparation needed.
- If a baby is not breastfed, the family will need to buy replacement milk for the baby and find time to prepare feeds and keep feeding equipment clean.
- If a baby is not breastfed, there may be loss of income through a parent’s absence from work to care for an ill child.
• Mother’s milk is all a baby needs:
- Exclusive breastfeeding is strongly recommended for the first six months. The baby does not need water, other fluids, or foods during this time.
- Breastfeeding continues to be important after the first six months when other foods are given to the baby.
- A mother's milk is especially suited for her own baby and changes from day to day, month to month, and feed to feed to meet the baby's needs. The baby learns the tastes of the family foods through the flavours of breast milk.
- Mother’s milk is unique (special). Human milk is a living fluid that actively protects against infection. Artificial formula provides no protection from infections.
Practices that can help breastfeeding to go well
• Hospital practices can help breastfeeding to go well. These practices include to: - Have a companion with you during labour, which can help you to be more
comfortable and in control.
- Avoid labour and birth interventions such as sedating pain relief and caesarean sections unless they are medically necessary.
- Have skin-to-skin contact immediately after birth, which keeps the baby warm and gives an early start to breastfeeding.
- Keep the baby beside you (rooming-in or bedding-in), so that your baby is easy to fed as well as safe.
- Learn feeding signs in your baby so that feeding is baby-led rather than to a schedule.
- Feeding frequently, which helps to develop a good milk supply.
- Breastfeeding exclusive with no supplements, bottles, or artificial teats.
• It is important to learn how to position and attach the baby for feeding and a member of staff will help after the baby is born. Most women can breastfeed and help is available if needed8.
Information on HIV testing
• All pregnant women are offered voluntary and confidential HIV counselling and testing. If a woman is HIV-infected there is a risk of transmission to the baby during the pregnancy and birth, as well as during breastfeeding. If the pregnant woman knows that she is HIV- positive then she can make informed decisions.
• About 5-15% of babies (one in 20 to one in seven) born to women who are HIV-infected will become HIV-positive through breastfeeding9.This means most infants born to women who are HIV-positive will not be infected through breastfeeding.
• In some settings, the risk to the child of illness and death from not exclusively
breastfeeding is higher than the risk of HIV transmission from breastfeeding. One of the reasons that individual counselling is so important is that it gives mothers the information they need to make the informed choices about how to feed their babies in their own situations.
• The majority of women are not infected with HIV. Breastfeeding is recommended for: - women who do not know their status, and
- women who are HIV-negative.
Assistance is available
• More information is available and a pregnant woman or mother can discuss any questions with a staff member.
• A skilled staff member will be available to assist with breastfeeding after the baby is born.
8 We will discuss these practices more in later sessions of this course.
9 To estimate the percentage of infants at risk of HIV through breastfeeding in the population, multiply the prevalence of HIV by 15%. For example, if 20% of pregnant women are HIV-positive, and every woman breastfeeds, about 3% of infants may be infected by breastfeeding. (Infant Feeding in Emergencies, Module1).
• Before a mother leaves the birth facility she will be told how to find on-going help and support with feeding her baby.
- End of talk ask if there are any questions on the points in the talk.
Individual discussion during pregnancy
Fatima goes in to see her pregnancy care provider. He or she does not know if Fatima heard the group talk on breastfeeding and if she has any questions.
Ask: How can the pregnancy care provider find out if a pregnant woman knows about the importance of breastfeeding or has questions?
Wait for participants to respond.
Start the discussion with an open question • Begin with an open question such as:
“What do you know about breastfeeding?”
This type of open question gives an opportunity to reinforce a decision to breastfeed, to discuss any barriers that the woman may see to breastfeeding, or to discuss problems the woman may have had with previous breastfeeding.
Ask: If you asked a question such as “Are you going to breastfeed?” or “How do you plan to feed your baby?” what might the mother reply?
Wait for participants to respond.
• If you ask a question such as “Are you going to breastfeed your baby” it is difficult to continue the discussion if the pregnant woman says that she is not going to breastfeed. Use your communication skills to continue the discussion
• Let the pregnant woman discuss her individual worries and concerns about feeding her baby. It is important that the discussion is two-way between the pregnant woman and the health
worker, rather than a lecture to the woman.
• If the woman’s comments tell you that she already knows much about early and exclusive breastfeeding, you can reflect and reinforce her knowledge. You do not need to give her information that she already knows.
• A woman’s decision about how to feed her baby may be influenced by the baby’s father, her own mother or another family member. It can be helpful to ask:
“What people are there who are close to you who will support you to feed your baby?” You may suggest that a family member who is important to the woman comes with her to hear more about feeding her baby.
Antenatal discussion is an important part of care
• An individual discussion on breastfeeding does not need to take a long time. A short focused discussion for three minutes can achieve much.
• A pregnant woman may see different health workers during her antenatal care. All health workers have a role in promoting and supporting breastfeeding. Some hospitals use an Antenatal Check List10 in the woman’s file to record discussions and highlight points to discuss further at another visit.
10
- (Optional) Give participants a copy of the Antenatal Checklist and discuss if it would be
useful in their work setting.