When a baby is born he is no longer fed via the placenta, the organ that maintained his needs throughout pregnancy. His nutritive requirements now need to be met by his mother, and in the developed world, this is a source of anxiety and concern for many women. They worry about whether the baby is ‘getting enough’ (McInnes & Chambers 2008) as well as whether they are ‘doing it right’ as a mother. The two main methods of feeding are with breast milk and formula. Breast milk is acknowledged as being the most appropriate source of nutrition for babies in the majority of circumstances. The World Health Organization (WHO) states that:

It is recommended that women should feed their babies exclusively on breast milk for the first six months and continue breastfeeding until the child is 2 years or more (WHO/UNICEF 2003). Yet there is evidence that women in the developed world do not tend to feed their babies long term and often lack support to help them (Renfrew & Hall 2008).

Some women are influenced to breastfeed their baby, before they become pregnant, through exposure to other breastfeeding women (Hoddinott & Pill 1999). There are also societal, cultural and sexual factors involved in their choice (Hall 1997). A midwife’s role is to support women in making the best choice for her and her baby, usually beginning in the antenatal period, and then to support and enable her in her chosen method. This chapter will consider the methods available to women and the midwife’s role in helping women.

New advances in ultrasound technology have enabled greater understanding of the anatomy of the human breast (Ramsay et al 2004). A clear picture of the anatomy can be found at: http://www.biochem.biomedchem.uwa.edu.au/Our_People/home_pages/academic_staff/hartmann/peter_hartmann/download.

During the later stages of pregnancy a woman’s body begins to prepare to produce milk for feeding (Kent 2007) which is known as secretory differentiation (Pang & Hartmann 2007). Levels of the hormone prolactin rise over pregnancy and continue to do so into the postnatal period. Levels of prolactin tend to be higher at night (Cregan et al 2002), thus breastfeeding at night should be encouraged in the postnatal period as this helps with the establishment of lactation. During pregnancy, the high levels of circulating oestrogens and progesterone prevent the breast from ejecting milk, though some colostrum may be produced in the second and third trimesters (Kent 2007).

After the birth of the baby and placenta, secretory activation is triggered and greater amounts of milk are secreted, accompanied by changes in the composition of the milk (Pang & Hartmann 2007). The timing for this is from 24–96 hours after birth and will vary from women to woman and birth to birth. It is thought that little milk is stored in the breast ducts as these are for transporting the milk (Ramsay et al 2004). Though it was previously believed that breast milk regulation was through a supply and demand system stimulating the production of prolactin, there is evidence that regulation is connected to how full each individual breast is and the capacity of that breast to store milk, as well as the stimulation of the infant at the breast (Daly & Hartmann 1995). However, there is further evidence that there are many physiological processes at play for breastfeeding to be initiated including the context of the early moments and days of breastfeeding (Colson 2007).

Midwives can help women breastfeed by having a positive attitude, keeping hands off when helping with positioning baby at the breast, being aware of women’s thoughts and feelings and spending time with them. The UNICEF Baby Friendly Initiative was devised to provide maternity services with guidance to ensure the ideal care is given to support women. They created ten steps that would indicate that the service is shown to be ideal (WHO/UNICEF 1989).

The ten steps are listed in Box 10.1.

These ten steps apply to all areas where babies are cared for, which includes postnatal wards, neonatal units and in the community. Maternity units can achieve ‘baby friendly’ accreditation following an assessment of their implementation of the ten steps.

A Cochrane review into the types of support available to breastfeeding women, examining 34 studies which included about 30000 women, showed that both professional and lay support and the two combined, could be effective in areas where breastfeeding rates were not high (Britton et al 2007). A qualitative synthesis of women’s experiences of support (McInnes & Chambers 2008) concluded that:

The basis of helping women to feed is to facilitate them to do this with their baby, rather than ‘taking over’ and ‘doing it to them’ (McInnes & Chambers 2008).