Respecting breastfeeding choices: although the ideal is for women to start breastfeeding as soon as possible after birth and to room-in with their babies, not all are physically and pyschologically ready to do so. Midwives need to be flexible in their attitudes and practice with these women.

Promotion of breastfeeding and the knowledge that "breast is best" are now widely accepted--the benefits of breastfeeding have been known for generations. Accordingly, health professionals are expected to make every effort to promote and assist women with breastfeeding from the outset.

Most commonly, the baby has a strong urge to suck and the new mother is keen to breastfeed her newborn from birth. However, there are differing views as to the significance of this first feed. Some say it can "make or break" long-term breastfeeding success; (1) others say no conscious effort is needed; (2) while other commentators point to the controversy over the importance of this early first feed. (3) Then of course there are the wishes of parents. Breastfeeding, from its earliest establishment, continues to elicit contrasting views and conclusions.

Obviously a successful early feed is the most desirable outcome when considering the physiology of lactation. However, for one reason or another, it is not always obtained. Regardless, we should never tell a mother who has not succeeded in giving an early feed to her baby that she now has no chance or has severely affected her ability to successfully breastfeed her newborn. Mothers need to enjoy feeling successful; after birthing and then to have the desire, the support and be in control to gain confidence and commit to ongoing breastfeeding.

Emotional changes after birthing are often overwhelming and can range from distress, exhaustion, sadness and rejection, to relief, elation and pride. The hormone balance changes as the body gains postpartum equilibrium and the baby's behaviour at this time is typically unpredictable. Therefore, enforcing any rigid practice on women appears to contradict the midwives' philosophy to provide individual, flexible, creative, empowering and supportive care. To explain at length to a tearful, exhausted young mother in the early hours of the morning the grave consequences of giving her baby a small complementary feed (if that is what she requests) could suggest complete insensitively and intolerance of her wishes and needs. This is not to say her choice is ideal, but it may be right for her and in fact keep her breastfeeding, this being the ultimate goal of midwives. We do not want this mother to feet negative towards those most wanting to help her. Our ultimate aim is to work in partnership with her.

Caring for mothers as well as babies

Rooming-in needs to be a choice for mothers. Its benefits should be explained and the practice encouraged, but it should not be enforced by a lack of options, nor should the mother feet a sense of failure if it is not practised. According to British psychologist Penelope Leach, there is no evidence to show that short periods of separation between mother and baby leave any permanent gap in the mother/baby relationship or hinder the establishment of long-term successful breastfeeding. (4) Many women, immediately after giving birth, are in need of care themselves and an opportunity for uninterrupted sleep and respite from baby care can be the ideal preparation for tackling new responsibilities. For many new mothers, lack of sleep is the worst part of parenting. Sleep deprivation predisposes them to postnatal "blues", depression and, at worst, postnatal psychosis which is detrimental to maternal health, along with the inevitable affects on the baby and family in the treatment and consequences of these conditions. (1) Anecdotal evidence has shown that relief from infant care can actually promote breastfeeding.

Empowering new graduates

The ability for new midwifery graduates to develop confidence and autonomy, just like the new mother, could be seriously marred if they are given little scope to trust and implement their own management plan after assessing a particular situation. National guidelines on breastfeeding as best practice are in place for all midwives, but we have autonomy within our scope of practice. Awareness that all cultures deal with breastfeeding initiation and maintenance differently shows tolerance and acceptance. All midwives must be mindful of ethnocentrism.

Ministry of Hearth statistics show our breastfeeding rates compare favourably with other countries of the Organisation for Economic Co-operation and Development. (5) Is it possible to increase these rates further? We must consider the continuously evolving women's role in society. Expecting women to continue breastfeeding in an unsupportive work environment could be just another pressure. Effort is needed to target areas where rates have been consistently lower, ie from the fourth to the sixth week after birth onwards, when rates fall dramatically.

It is vital we continue to reflect on our practice and discuss our views and experiences, to ensure midwives provide a progressive service. As midwives working together, we must ensure a safe, holistic and tolerant practice and not simply see "boobs and babies" as the only component of the postnatal experience. After all, women are more than that. Both parties want an enjoyable and rewarding experience and partnership. Our clients are a diverse group with many interesting and contemporary lifestyles, political views and expectations. Our goal should be to respect women's choices and ensure those choices are safe and healthy for both mother and baby.

References

1) Riordan, J. (2005) Breastfeeding and human lactation (3rd ed). Boston: Jones-BartLett.

2) La Leche League International. (1988) The womanly art of breastfeeding (4th ed). AustraLia: Angus-Robertson.

3) Dennis, C. (2002) Breastfeeding initiation and duration: A 1990-2000 Literature review. Journal of Obstetric, Gynecologic and Neonatal Nursing; 31: 1.

4) Leach, P. (1997). Your baby and child, Auckland: Penguin.

5) Ministry of Health Manatu Hauroa (2002) Breastfeeding: a guide to action. Wellington: Author. (can be accessed from http://www.moh.govt.nz/moh.nsf/O/C1A26AE746D7B471CC256C770008660D)

Wendy Hicks, RN, RM, is a midwife in Hawke's Bay.