Best for Babes

Finding a Breastfeeding-Friendly Prenatal Care Provider, Hospital, and Pediatrician

 By Danielle Rigg, JD, CLC and Bettina Forbes, CLC

© 2009 Best for Babes Foundation.  All Rights Reserved.

Make no mistake about it, breastfeeding is a team sport!  You and your little babe(s) are the main attractions, but you definitely need star players around you to succeed!  In the breastfeeding arena, this translates into enlisting knowledgeable help so that you have as smooth an experience as possible. This is what we refer to as assembling your “A-Team” and it’s something that is critical for you to do while you are still pregnant.  Sure, breastfeeding is a normal and instinctive behavior, but it is also a skill that both you and your baby need a bit of time and patience to master.  (See our section “The Learning Curve.”) 

Cheesy but true: A good A-team can coach and cheer you on!

Getting off to a good start will help you avoid the “booby traps” and unnecessary troubles. (See our section “The Breastfeeding Booby Traps.”) Your A-Team can get you to the starting line with a “can-do” attitude (essential!), help you hit your stride over any early bumps, and see you through to a rewarding finish (of your choice– not circumstances)!  Sounds a whole lot better than showing up for the race of your life in flip flops, without any training under your belt, right? 

A General “Rule of Thumb” to find most supportive breastfeeding doctors: 

The fastest way to connect yourself with the medical professionals in your community who will deliver when it comes to breastfeeding is to ask someone who daily interacts with and/or supports breastfeeding mothers — your local La Leche League leader (http://www.llli.org), a lactation consultant (http://www.ilca.org, http://www.breastfeeding.com), a labor or postpartum doula (http://www.dona.org), or a childbirth educator.  These women deal with birth and breastfeeding every day, helping new moms walk this path over and over again.  They have seen the trials and the triumphs and, therefore, they usually know exactly which OB and Pediatrician to choose if you want great breastfeeding support.  If you can’t get in touch with any of these people, then you at least need to know which questions to ask when you do your interviewng. (See below.) Well, you ask, what’s wrong with trusting the recommendation of a good friend, or selecting a doctor on your own?  You can.  But we are interested in helping you escape the “booby traps”!  And one of those traps is winding up with a doctor who really doesn’t do more than pay “lip service” to “breast is best” while women in his practice struggle through all sorts of problems and eventually give up nursing!  We want you to know the sad reality that too many doctors are undereducated about nursing and/or they are too squeezed for time to deal with breastfeeding issues so that you don’t wind up not getting the help you are expecting from the person whom you expect it most.  (For more on identifying physicians who are not supportive, see Dr. Newman’s handout.  If you are going to rely on the advice of a friend, make sure it is someone who breastfed successfully with the help of the physician she is recommending.  Not someone, who succeeded despite the poor breastfeeding help she received or someone who pitched it in early because of that lack of help.   

Having said all that, there are some excellent care providers out there who can give you the breastfeeding support you need.  If you can’t shortcut the search for your A-Team by contacting some of the new mother folks we mentioned above, here is an excellent guide to picking out your A-Team and the questions to ask: 

 1.    Your Prenatal Care Provider. Your Ob/Gyn, Family Doctor or Midwife who you will see for prenatal care, is the first line in helping you succeed.  Why?  First of all, studies show that “women who receive early, comprehensive breastfeeding instruction and guidance are more likely to breastfeed for at least three months and to enjoy the experience from the start.”  (Guise, JM, Palda V, Westhoff C, et al., The effectiveness of primary care-based interventions to promote breastfeeding: systematic review and meta-analysis for the US Preventive Services Task Force.  Annals of Family Medicine 2003; 1 (2); 70-8.)   A prenatal care provider who is knowledgeable and encouraging about breastfeeding can, therefore, start the conversation with you while you are pregnant, discuss any reservations you might have, give you the pointers you need to succeed, or at least be able to point you in the right direction of help.  Secondly, a great doctor/midwife knows that how you birth will impact how well (or not) early breastfeeding goes:  Research shows that babies who are born after scheduled inductions and c-sections, (Dewey et al, 2003) who are the product of forced extractions (forceps and vacuums) and heavily medicated labors, (Hall et al, 2002), often have a difficult start at nursing, (Smith, 2007), which can adversely impact how long breastfeeding continues. Of course, these interventions are sometimes necessary, and the breastfeeding challenges they may present can be overcome with extra support. (See our “Fast Facts” section for more on Common Breastfeeding Problems; for more on the birth process watch Ricki Lake’s video, The Business of Being Born.) 

So, how do you choose a breastfeeding-supportive Prenatal Care Provider?

• Observe whether the office displays formula advertising and coupons.  Notice if your care provider discusses breastfeeding with you during early visits, listens to your concerns, and offers resources.  A breastfeeding-friendly doctor/midwife will not only ask you if you are planning to breastfeed, but will sense if you have any hesitations and talk to you about it in a supportive and non-judgmental way.   [S]he will help you get to the bottom of any reservations towards breastfeeding you may have without judgment and point you in the direction of resources, such as reading material and a great breastfeeding class.   
• Remember, how you birth will impact your early breastfeeding experience.  Find out your MD/midwife’s caesarean rate—the United States has the highest rates, somewhere around 37%, when the World Health Organization (WHO) says that any time a country’s cesarean-section rate rises above 15 percent, the dangers of C-section surgery outweigh the lifesaving benefits it is supposed to provide.  (And only 7% of c-sections are medically necessary.) World Health Organization, “Appropriate Technology for Birth,” The Lancet ii (1985): 436-437.  We are not talking about medically necessary c-sections.   If the doctor you are interviewing specializes in high-risk pregnancies, you can expect that the caesarean rate will necessarily be higher.  Our concern is with scheduled c-sections for doctor or patient convenience, or c-sections that come about from excessive and often unnecessary medical interventions.    Ask your MD/midwife about his/her attitude towards unmedicated births, birth alternatives, and using doulas, whether or not you are leaning in that direction.  A good doctor is open-minded and will discuss whether these options would be suitable for you if you are interested in pursuing them.
• Ask him/her when you should start breastfeeding?  If he/she does not say, “barring any serious complications, immediately after birth”, a red flag should go up. The theme of 2008 World Breastfeeding Week was “Latch Within the First Hour” because of the positive effect that breastfeeding right after birth has been shown to have on its ultimate success. 

 2.  A Baby-Friendly™ or Breastfeeding-Supportive Hospital.  Want success?  Go where there is a track record for it!  Where you give birth is incredibly important to the kind of breastfeeding help you will get.  Unfortunately, only 3% –yes, that’s three percent–of U.S. hospitals are certified as Baby-Friendly™, which means they agree to implement policies and practices which are proven to result in a high rate of breastfeeding success.  You can check to see if one of these fabulous hospitals is in your area at http://www.babyfriendlyusa.org.  If a Baby-Friendly hospital is not an option, arm yourself with information: find out about your hospital’s breastfeeding track-record and the kind of lactation help available.  Recently, the CDC conducted a survey of hospitals nationwide and revealed that most hospitals are not adequately supporting breastfeeding so this is incredibly important. (Associated Press: CDC: Hospitals do poorly on breast-feeding support, 6/12/08.)

 Here are the important questions you should ask: 

•  What percentage of mothers breastfeed exclusively (no formula supplementation) at discharge?  Any number less than 50% is too low, and ideally, the number should be very high!
  

  A BFHI "Baby-Friendly" Hospital

• What kind of lactation help is available, and is it 24/7? Ideally, you want your hospital to employ several full-time, board certified lactation consultants (IBCLCs) who are available to you 7 days a week. The reality in most places is very different: most hospitals do not employ LC’s around the clock or on weekends!  So, for example, if you deliver without complications on Friday at 5pm, you may be discharged before the LC returns on Monday morning!  Many hospitals claim to have fixed this problem by requiring some of their general nursing staff to also be “lactation specialists.” Unfortunately, many hospital lactation specialists are woefully undereducated about breastfeeding.  We strongly suggest that you ask, other mothers about their experience with the lactation help in that hospital. If you get lukewarm to poor reviews, you may need to call in your own lactation help (see below). 
• Will someone with training place the baby skin-to-skin on you after birth and help facilitate a first latch?  Skin-to-skin between you and your newborn is a proven way to draw on her instinct to find your boob and begin nursing.  Unmedicated babies are even capable of crawling to the breast by themselves and self-attaching! (see Lennart Righard and M. Alade, “Effect of Delivery Room Routines on Success of First Breast-feed,” The Lancet 336, no. 8723 (3 November 1990): 1105–1107.)
• What is the hospital’s policy on breastfeeding in the delivery room?  How long will the baby stay with you in the delivery room? Will the baby be taken to the nursery for routine tests, i.e., measurements, weighing, bath, and  immunizations?  Will they respect your request to delay these things until after the first latch? Many hospitals now agree that the first bath should be left until the second day of life because it unnecessarily lowers your baby’s body temperature which, in turn, can cause the need for more interventions, which in turn can interfere with breastfeeding.  
• Does the hospital give out free formula-filled diaper bags?  Many hospitals are now banning this practice as evidence shows these giveaways are anything but “free”– they are a carefully marketed ploy that has been shown to reduce the number of babies who wind up breastfeeding.   See http://www.banthebags.org.
• Do they encourage 24 hour “rooming-in” with baby?  Studies prove that rooming-in boosts breastfeeding rates, plus moms are less anxious and better bonded to their little babes, leading to better sleep for both.  
• Do the LC’s offer any breastfeeding follow-up once you are home?
• Do they have a breastfeeding “hot” or “warm” line? A hot-line is “live” telephone support 24 hours/7 days a week.  A warm-line means 9-5 or less, and you might get an answering machine. 
• Do they offer a breastfeeding support group?  Many hospitals do.  Surrounding yourself with other nursing moms in this environment is a proven way to continue breastfeeding and to keep enjoying it!  Plus, you get your questions addressed for free, and get some mommy-time too! 
• What kind of lactation help is available, and is it 24/7? Ideally, you want your hospital to employ several full-time, board certified lactation consultants (IBCLCs) who are available to you 7 days a week. The reality in most places is very different: most hospitals do not employ LC’s around the clock or on weekends!  So, for example, if you deliver without complications on Friday at 5pm, you may be discharged before the LC returns on Monday morning!  Many hospitals claim to have fixed this problem by requiring some of their general nursing staff to also be “lactation specialists.” Unfortunately, many hospital lactation specialists are woefully undereducated about breastfeeding.  We strongly suggest that you ask, other mothers about their experience with the lactation help in that hospital. If you get lukewarm to poor reviews, you may need to call in your own lactation help (see below). 
• Will someone with training place the baby skin-to-skin on you after birth and help facilitate a first latch?  Skin-to-skin between you and your newborn is a proven way to draw on her instinct to find your boob and begin nursing.  Unmedicated babies are even capable of crawling to the breast by themselves and self-attaching! (see Lennart Righard and M. Alade, “Effect of Delivery Room Routines on Success of First Breast-feed,” The Lancet 336, no. 8723 (3 November 1990): 1105–1107.)
• What is the hospital’s policy on breastfeeding in the delivery room?  How long will the baby stay with you in the delivery room? Will the baby be taken to the nursery for routine tests, i.e., measurements, weighing, bath, and  immunizations?  Will they respect your request to delay these things until after the first latch? Many hospitals now agree that the first bath should be left until the second day of life because it unnecessarily lowers your baby’s body temperature which, in turn, can cause the need for more interventions, which in turn can interfere with breastfeeding.  
• Does the hospital give out free formula-filled diaper bags?  Many hospitals are now banning this practice as evidence shows these giveaways are anything but “free”– they are a carefully marketed ploy that has been shown to reduce the number of babies who wind up breastfeeding.   See http://www.banthebags.org.
• Do they encourage 24 hour “rooming-in” with baby?  Studies prove that rooming-in boosts breastfeeding rates, plus moms are less anxious and better bonded to their little babes, leading to better sleep for both.  
• Do the LC’s offer any breastfeeding follow-up once you are home?
• Do they have a breastfeeding “hot” or “warm” line? A hot-line is “live” telephone support 24 hours/7 days a week.  A warm-line means 9-5 or less, and you might get an answering machine. 
• Do they offer a breastfeeding support group?  Many hospitals do.  Surrounding yourself with other nursing moms in this environment is a proven way to continue breastfeeding and to keep enjoying it!  Plus, you get your questions addressed for free, and get some mommy-time too! 

 3.  A Breastfeeding-Friendly Pediatrician.  We can’t stress this one enough.  There are some wonderful pediatricians out there who have acquired the necessary knowledge of breastfeeding and who will become your most trusted resource and guide.  However, a very recent study delivered the disappointing news that attitudes towards breastfeeding among pediatricians are getting poorer (2004, Archives of Pediatrics & Adolescent Medicine) –even though the American Academy of Pediatrics mandates that pediatricians  “enthusiastically support and encourage” breastfeeding.  As we said earlier, most pediatricians are undereducated about breastfeeding because they are not required to be:  although more medical schools are now requiring completion of breastfeeding modules, previous graduates of medical schools are not required to undergo training.  The unfair result for too many new moms and babies, is that rather than guiding them victoriously through the maze of early breastfeeding, a pediatrician who is not trained in or is, even ambivalent about breastfeeding can really undo your confidence and put you on the road to breastfeeding problems and failures.  

 For these reasons, we recommend that you consider your choice in your baby’s first line of care very carefully.  Begin the hunting and interviewing process well before the birth.  Choose well, and you will be well-prepared to meet any challenges!  For more info on knowing when a physician is not supportive, see Dr. Newman’s handout.

Dr. Jack Newman & Edith Kiernan

So how do you know that you’ve got a breastfeeding-supportive pediatrician who is doing more than paying lip-service to “Breast is Best?” Here are some key questions for you to to ask:

•  What percentage of your patients are breastfeeding exclusively at one month?  A breastfeeding-friendly pediatrician will have many more mothers nursing than not.  
• Do you have any lactation credentials?  Some pediatricians are also IBCLC’s – harder to find, but some of the best. See below.
• Do you have an LC on staff or to whom you refer if needed?
• Under what circumstances, should a baby be taken off the breast and given formula?  The answer should be “almost never.” Although there are instances in which formula supplementation is necessary, they are rare, and should be accompanied by a thorough assessment of why the breastfeeding challenge arose in the first place.  Remember, feeding your baby formula will satisfy his/her hunger, but it will not address the underlying breastfeeding issue that caused the problem in the first place.  And  it will likely make whatever breastfeeding problem you are having, worse.  (See our section on “Supplementing“in “Fast Facts”.)  As Dr. Jack Newman, a leading pediatrician and lactation expert likes to say, “Fix the breastfeeding, and you fix the problem.”  (See http://www.drjacknewman.com for more wonderful and accurate information).
• For how long should I breastfeed?  The American Academy of Pediatrics recommends exclusive breastfeeding for the first six (6) months, continuing to at least one year with solid foods added, and beyond as long as desired.  The World Health Organization recommends at least two (2) years.   Beware if his/her answer is along the lines of:  “Breastfeeding is best, but it’s not for everyone” or “Either is fine, it’s up to you.”  A good pediatrician is unequivocal about breastfeeding and will help you work through or get help for any issues so that you can succeed, much as a coach helps you set realistic goals and achieve them.  He/she should not browbeat you or be judgmental either!    
• Do you know local breastfeeding resources and support groups to whom you can connect me?

Some dead giveaways that a pediatrician is not truly breastfeeding-friendly are:  his/her solution to sore nipples or other breastfeeding problems begins and ends with a sampler pack of formula and coupons; formula paraphernalia strewn about the office– coupons, buttons, pens, clip-boards. 

Please remember that these are simply suggested guidelines, as we believe that assembling an A-Team will give you a huge head start toward breastfeeding success! 

 The information in this document is in no way intended to diagnose or treat any medical condition and is not a substitute for an in-person evaluation by a breastfeeding-friendly pediatrician or qualified, independent Internationally Board Certified Lactation Consultant (IBCLC).