10 minute read
BREASTFEEDING CONNECTION
MILK SUPPLY – PERCEPTION, REALITY, ASSESSMENT AND FEEDING OUTCOMES
Qualitative and quantitative research indicates that maternal perception of insufficient milk supply can lead to supplementation of breastfeeds and shortened breastfeeding duration (Kent et al, 2012). If perception of milk supply is a potentially modifiable factor for breastfeeding continuance, is it important to assess the difference between perception and reality, and also to recognise the difference between a primary breast milk supply issue and a secondary issue? And, can low supply be turned into abundance in some situations?
CAROL BARTLE POLICY ANALYST
Using words like low supply, as opposed to the terms inadequate, insufficient and failure can have an impact on how a woman feels about “breastfeeding and her breastfeeding body” (Burns et al, 2016) as choice of language can have a positive or negative impact.
Knowing what factors can support lactation, breastfeeding initiation and breastfeeding establishment can assist women to meet their own breastfeeding goals. For example, Sandhi et al. (2020) found that high levels of maternal perceived breast milk supply were positively linked to skin-toskin contact or rooming-in, the experience of positive infant suckling behavior, and/ or self-efficacy in breastfeeding women. The study highlighted the importance of maternal perception of milk supply to positive breastfeeding outcomes. Galipeau et al. (2017) found that maternal self-efficacy had an impact on perception of low milk supply and suggested interventions should be directed at increasing maternal confidence. One of the most frequent reasons for not breastfeeding is described as a previous unsuccessful experience by Burns et al. (2020) and midwifery continuity of care and breastfeeding support, which includes peer counsellors, can increase women’s confidence and provide psychosocial benefits.
Low milk supply can be related to what are termed primary issues, and these can be linked to the amount of glandular tissue in the breasts, hormonal issues, previous breast surgery, or a severe postpartum haemorrhage. Secondary issues can occur alone, or alongside primary issues, and when both occur it may be difficult, if not impossible, to resolve issues of low milk supply. Secondary issues usually occur in women who do not have a primary reason and are caused by factors interfering with the usual lactogenesis process which should usually result in ample milk supply. Birth interventions, sleepy babies who are exposed to labour medication, separation of mother and baby, latching problems, scheduling feeds, pacifier usage, using breast-milk substitutes, lack of information and support, and early hormonal contraception have all been implicated.
Full milk production needs sufficient breast glandular tissue, synchronised balanced hormone production, intact nerve pathways and frequent effective removal of milk from the breast.
In terms of real or perceived issues with milk supply many women think they do not have enough milk when in reality it has been reported that approximately 2 to 5% of women may have a ‘real’ problem with their supplies. Perceived can quickly become real, however and as suggested by Stuebe (2012) it may not really matter whether real and perceived are counted together as, “… mothers are suffering, whether they lack glandular tissue, and/or they lack self-efficacy and support.”
Lactation, and its intimate companion breastfeeding, can be seriously compromised when a baby is not feeding directly at the breast which is why separation of mothers and babies can be damaging to breastfeeding. For a woman with an actual low milk supply, assessment and where possible rapid resolution of underlying issues, getting the best latch, using breast compression to support milk flow and implementing strategies to increase supply may be necessary. This will likely include at some point mixed strategies such as hand expression, breast compression, direct breastfeeding, supplementary nursing systems, using a breast pump, and in some cases galactagogues. Mother baby skin to skin contact is a first line action as is full evaluation of breastfeeds.
Where women have had previous difficult breastfeeding experiences and /or low milk supply it is particularly important to ensure uninterrupted skin-to-skin contact after birth, minimal disturbance of mother and baby, and support for the baby to proceed through the nine stages after birth while in skin-to-skin contact (Widström et al, 2011). This supports pre-programmed behaviours for bonding and breastfeeding. Attention to time and space, observation, and avoidance of interruption are recommended for all mothers and babies (Widström et al, 2019).
Supplementary nursing systems have been used successfully by many women for varying lengths of time and some women have continued to use them, with either donor milk or formula, for the duration of their breastfeeding journeys. Women who have low milk supplies, which have not increased to be able to fully meet their babies’ needs, may have planned to exclusively breastfeed, and facing their feeding realities may cause a degree of grief, sadness and disappointment.
Midwives can support women to come to terms with the reality of mixed feeding by providing compassionate and non-judgmental care and support, practical information about mixed feeding and assurance that providing some breast milk to a baby is very worthwhile. Some women may decide to fully formula feed and also need full support for their decisions.
Midwives can support women to come to terms with the reality of mixed feeding by providing compassionate and nonjudgmental care and support, practical information about mixed feeding and assurance that providing some breast milk to a baby is very worthwhile. Some women may decide to fully formula feed and also need full support for their decisions.
Olza et al. (2020) discuss birth as a neuro-psycho-social event and describe the neurobiological processes orchestrated by endogenous oxytocin release that facilitate labour and birth. These physiological experiences of labour are described as transformative and facilitative of the transition to motherhood, with human touch, support and reassurance facilitating oxytocin-mediated reduction of fear, stress and pain as well as the promotion of joy and empowerment. Striving for the same physiological experiences, reassurances and transformation of breastfeeding events, within a “feminist and humanistic attitude” (Olza et al, 2020), may go some way to supporting women to either meet their own goals for breastfeeding, or assist women, who will continue to have milk supply issues, to reconcile their modified infant feeding plans and to combination feed if they wish to do so. square
References available on request.
THE FUNDING PACKAGE FOR MIDWIVES - DOES IT ADD UP FOR YOU?
The Government recently announced $242 million of funding for maternity services. New Zealand College of Midwives chief executive Alison Eddy speaks to Maria Scott about what it means for self employed midwives after their five-year struggle over pay and conditions.
The headline figure of $242m seems impressive and has been described as the “largest ever funding boost for primary maternity services”. Is it all that it seems?
Yes and no. These funds are intended to be spread over four years; this current year and the following three. Not all of it is going directly into midwives’ pockets through Section 88 payments. Also, the headline figure includes some funding the government had already announced, including the $2,500 for each eligible self employed midwife to cover the extra costs of practising during the Covid response.
What can self employed midwives expect to see in their pockets and when?
This will depend on the nature and location of your practice and your caseload. At the time of writing the College was still working on the detail with the Ministry but by the time Midwife magazine reaches you in mid September we hope to have a much clearer idea.
Funding of $85m will go into Section 88, equivalent to $21.25m a year this year and the next three. This is on top of the already announced 2.18% increase to Section 88 payments from 1 July this year. There will be further increases of 2.18%, in addition to the annual $21.25m increase for a further three years after this financial year.
Modules within Section 88 for LMCs, most of whom are midwives, cost approximately $160m in the year to 1 July. So this additional $21.25m equates to an approximate increase of 15% in the LMC Section 88 budget.
Can you give us more information about how the different modules will be boosted?
The 2.18% rise mentioned above is applying across all modules. But the new funding of $21.25m for this and the next three years will be targeted to midwives working in rural areas and with women who have greater needs. The intention is to add new modules of care to address the needs of these midwives and one aspect of this will be a new definition of rurality. The Ministry is required to undertake a formal consultation process to make substantive changes to the Primary Maternity Services Notice and it is anticipated this process will have commenced by the time Midwife magazine reaches members. So there will be a new Section 88 Notice eventually but this is not due to be ratified until 1 April next year.
So do self employed midwives have to wait until then to see their incomes rise?
No. The College has been in discussion with the Ministry on an interim solution so that funding can be claimed before that. This funding has to be targeted to the areas allocated in the budget: rural midwives and women with complex needs. In the short term this means an increase in rural travel and to the third trimester modules. The arrangements for these payments are part of the discussions underway at the time of writing and which the College hopes to have been able to confirm by the time this edition of Midwife is published. We will be keeping members informed.
So will any of the $21.25m - $85m over four years - go towards increases across all modules or will all be directed to areas of high need?
In the short term, until the new Notice is ratified, the answer is no, it will just go to rural travel and third trimester modules. In the longer term (post 1 April) we simply don’t know the answer to that, until we have seen the new Notice proposal and how funding will be allocated across its modules.
We have been fighting for five years for improved pay and a new funding model. Do you think this is a fair deal for community midwives?
Overall, we do not see this $242m as full and final settlement to our long standing concerns over pay and conditions. Our court case led to mediation and a legal agreement with the government that we expected to result in a new funding model for midwifery.
This appears to have been shelved although not all of the work undertaken by the profession to develop proposals for this model has been wasted. We understand that it has been used to reshape the modules now under development. We still want to see a very different funding model for the future.
We understand that there will be another business contribution payment this year but are unhappy that there does not appear to be any intention to continue this beyond this financial year. We understood that this was allocated for two years with a view to having a new payment model in place by now and this has not happened. We will continue to raise this with the Ministry.
However, we are very mindful of the wider circumstances New Zealand finds itself in now as a result of the pandemic response. We know that midwives are aware that many families are facing significant hardship.
Where do we go from here?
We will continue to look at our options for legal redress over the failure of the government to meet the terms of our mediation agreement. The government has allocated $35m from the $242m towards the Maternity Action Plan, an outline plan announced some time ago. It is not clear to us what the aim of the plan is and what the government is trying to fix with it. From what we have seen so far we are not convinced that the money wouldn’t be better spent on better pay for midwives and existing services.
We will also be watching the development of proposals for new maternity service initiatives, in line with the recentlypublished Health and Disability System Review recommendations for which $60m of the $242m has been allocated. We think the review points towards more influence for DHBs over the community midwifery workforce, including funding. We think this could undermine resourcing and the continuity of care model that we know works so well for women. So, yes, there is much more to do. square
