The advantages of breastfeeding are well known, and programs such as the World Health Organization's Baby Friendly Hospital Initiative have ensured that breastfeeding is encouraged in maternity settings throughout the world. However, in my practice I've often struggled with the emphasis nurses place on the evidence-based, population-health perspective of breastfeeding promotion. In certain cases, this can interfere with the nurse–patient relationship, in which patient care is, ideally, planned in an egalitarian, collaborative fashion. At times I've wondered if, in following guidelines, I've overlooked important signals from women—signals indicating that persevering with breastfeeding wasn't the best course of action for them.
Breastfeeding promotion is unique among health initiatives for many reasons. For one, infant feeding is often closely associated with women's perceptions of successful mothering and therefore invokes unusual passion among nurses and mothers alike. Also, decisions about infant feeding are time sensitive—milk production requires the ongoing stimulation of feeding or pumping.
However, reports in the literature as well as my own experience suggest that some women feel pressured and coerced by nurses to breastfeed their infants. This is an unfortunate byproduct of nurses' passion for breastfeeding promotion; a passion that may be influenced by best practice guidelines that endorse the notion that breastfeeding is attainable for all.
I was particularly struck by the dissonance between patient circumstances and nurses' ideology while caring for women who had mood disorders, which can complicate decisions about infant feeding. One woman told me she longed for "permission" from her nurses to discontinue breastfeeding because of the many difficulties she experienced with latching on and painful nipples. Instead, they encouraged her to persevere, failing to recognize the deep depression that was emerging in this patient, or the anxiety that accompanied her attempts to breastfeed. In our later talks, she indicated a strong resentment toward her nurses, who'd suggested that her anxieties regarding the challenges of feeding were less important than the baby's right to be breastfed. This in turn exacerbated her feelings of guilt and shame following her eventual decision to feed her infant formula.
Another woman chose not to breastfeed because of the risks associated with psychotropic medication transfer through breast milk. Unfortunately, when she explained to her prenatal class that she wouldn't be breastfeeding, the prenatal educator implied that this decision represented a lack of proper commitment to her infant's health. The educator made this judgment without fully knowing the woman's history with bipolar disorder—information the expectant mother preferred not to share. This experience eroded the woman's confidence, and she worried about how nurses would judge her after she delivered her baby.
Some women won't or can't breastfeed, and they may or may not share their rationale for this decision with their nurses. Yet the woman who lacks the will to continue breastfeeding in the face of common challenges—the pain and frustration of correcting an improper latch, for instance—is typically encouraged to persevere. Strategies, such as pumping breast milk a few times a day, might be suggested to allow the woman's nipples to heal while maintaining the milk supply. While these efforts could help some mothers continue breastfeeding, they might cause undue angst in others.
At present, no clear guidelines exist to assist nurses with the complexities of infant feeding choice, except to promote breastfeeding as the ideal method. However, collaborative decision making is possible if nurses commit to open, nonjudgmental communication with the mother and engage in an ongoing assessment of maternal mental health status.
One thing is clear: attention to situation-specific exigency is important if nurses are to offer the most insightful and compassionate care possible.