Initiation and maintenance of breastfeeding: the need for essential support

Breastfeeding has proven health benefits for infants and their mothers and economic benefits for the family and society. Therefore, the World Health Organization and other key agencies have recommended exclusive breastfeeding for the first 6 months of an infant’s life [1, 2]. To provide essential support to initiate and maintain breastfeeding requires an understanding of the factors associated with parents’ choices for starting and maintaining breastfeeding.

Factors influencing the initiation of breastfeeding include maternal characteristics: maternal education attainment [3], marital status, education attainment, smoking, participation in an education program for nutritional supplements for mothers, infants, and children [4], unwanted pregnancies [5], delivery of a low birth–weight infant [6], and postpartum depression [7]. Therefore, it is important to consider these factors in the design of reasonable access to breastfeeding support services and better targeting [8, 9, 10].

Alhaji et al. have reported in this issue a study of the outcomes of paid maternity leave on the maintenance of exclusive breastfeeding in Brunei [11]. Implementing a new maternity leave regulation to extend paid maternity leave in Brunei (effective January 2011) moderately increased exclusive breastfeeding at 6 months of infant age by 12 percentage points, from 29% in 2010 to 41% in 2013. The increase was seen in both mothers employed by the government and those employed in the private sector [11]. However, paid maternity leave alone is not sufficient to effect change in exclusive breastfeeding practice, particularly for primiparous mothers, mothers with male infants, and other subgroups such as those with sore nipples and erroneous perception of inadequate milk supply and therefore not meeting the needs of their infants [12, 13]. Reasons for early termination within the first month of exclusive breastfeeding include sore nipples, perception of inadequate milk supply, and concerns that their infants had difficulty in breastfeeding or were not satisfied by it. Women who choose formula feeding often lack confidence in their ability to breastfeed because of concerns that their infants prefer formula or that they have an inadequate milk supply [14].

The success of exclusive breastfeeding is dependent on health care professionals providing education and support to new parents, and a birthing environment conducive to the initiation of breastfeeding [15]. This education and support should include a combination of pre- and postnatal breastfeeding educational programs, as distinct from either phase alone or onetime intervention. Useful antenatal programs unite education about breastfeeding and behaviorally-oriented counseling; useful maternity care programs include practical skills training and problem-solving, as well as didactic instruction of individuals or small groups by lactation consultants or specially trained nurses, and ongoing postpartum support [15], especially support by peers trained by health professionals [16].

Clinicians from a broad range of disciplines should be encouraged to guide and support exclusive breastfeeding by providing prenatal counseling and educating mothers during hospitalization and after discharge. Guidance and support can be individualized, although postnatal support from community midwife-led groups is effective [17]. Personalized therapeutic drugs and maternal and neonatal conditions should be reviewed to identify and address any potential contraindications of exclusive breastfeeding.

A combined effort from various disciplines based on an understanding of the nature and extent of problems associated with exclusive breastfeeding can be expected to produce a healthier human resource for the world.