“When I was studying medicine, I had a total of eight hours on dietetics. At the end of eight hours, I realised I knew nothing about dietetics. I now understand why people spend four years studying to become a dietitian.” — Dr Karl Kruszelnicki
Many new mothers run into breastfeeding troubles soon after having their baby.
We know this because 96% of Australian mothers initiate breastfeeding, however by two months of age, a whopping 50% of babies are fully or partly formula fed. By 5 months of age, only 15% of babies are exclusively breastfed.
Right after she gives birth, a new mother mostly receives critical breastfeeding advice and support from midwives, her obstetrician, a paediatrician, her local maternal and child health nurse and sometimes her local doctor.
You'd be forgiven for thinking that she'd be receiving the very best medical advice and information. Because after all, these highly trained and skilled medical professionals have studied for many years, and work with breastfeeding women all the time, right?
Well, there's something you really need to know before you ask a healthcare provider for breastfeeding advice — because I'm about to tell you something that may shock you. It has the potential to significantly impact on your breastfeeding journey. Here it is:
Most medical healthcare providers receive anywhere from zero to three hours of breastfeeding information in their entire undergraduate course curriculum.
While the amount of breastfeeding education varies at each individual training organisation, the average number of hours is around two for all of these key healthcare degrees and diplomas. Compare this to an International Board Certified Lactation Consultant (IBCLC) who has 90 hours of education — not to mention their other intensive qualification requirements. And note, this is not just an issue isolated to Australia (see this article from the US).
Zero to three hours is absolutely nowhere near enough to learn about the biology and structure of the breast, latching, maternal breastfeeding problems and issues, baby related breastfeeding problems and issues, contraindications, referral pathways, how to effectively support a new mother and more.
Sure, these healthcare providers don't really need to be experts in breastfeeding, since they intended on studying something else. But, for a long time now, this is where new mothers have been getting most of their advice – and it's clearly not doing our flailing breastfeeding rates any favours.
Jessica Leonard, Breastfeeding Counsellor for the Australian Breastfeeding Association says:
“There are certainly some cases we hear about where mothers are not given enough support by health professionals to manage breastfeeding issues. I've counselled mums who have been given the advice to top up with infant formula, without the ongoing support to both protect the milk supply and fix the underlying problem that caused the need for top ups in the first place.”
For a society that highly values seeing specialists for everything medical and health related, for example an obstetrician or midwife for childbirth, there is a severe lack of referral and acknowledgement when it comes to much needed breastfeeding specialists. An IBCLC is the most qualified breastfeeding expert available. They are required to have extensive training, huge experience hours, and regular, ongoing testing, in order to retain their qualification.
A MOTHER SAYS: “I had to be informed by a friend, as the hospital support was terribly inadequate, even at the clinic they had. I had someone show me twice how, one was rough and upset me by jamming us together. A lactation consultant came to my home after a friend visited me, and saw my face and gently asked if I needed any help. Had my friend not come when she did I'm certain our breastfeeding journey would have failed. I'm forever in debt to her, she might not know how much she helped me but she did and changed our lives… literally. That [IBCLC] was the best money I ever invested, hands down!” — Irene Sheard
Breastfeeding – Not Important?
You begin to wonder how important breastfeeding is to those who run our country, when you see the many hurdles for breastfeeding research and funding. No-one stands to make money from breastfeeding (although the government would save huge taxpayer dollars for the healthcare system if they bothered to acknowledge it). So who will invest in something that you can't profit from?
Miranda Buck, an IBCLC at the Royal Women's Hospital in Melbourne says: “Honestly it's seen as a whole ‘women's health' issue. If you go look at research for any number of issues from blood pressure changes in the postpartum period and lactogenesis II, or the impact of breastfeeding during pregnancy, there's almost nothing. If you look at the cancer council web pages about prevention of cancer, they don't mention breastfeeding – which we know has a significant impact on breast, ovarian and endometrial cancers in women who breastfeed. We have ridiculous amount of difficulty finding funding for research. We really need a breastfeeding research centre.”
She continues, “Funding for breastfeeding support is funding for 96% of new mothers and their babies – it doesn't get more vital for our society.”
Note from BellyBelly: Right on cue, it has just been announced that a world first breastfeeding research centre will be opening in Australia in July. For more information, see our story here. We hope this is one of the big steps forward that we need.
A MOTHER SAYS: “I've had no support to breastfeed and am still finding it very difficult, most of the doctors I've spoken to have told me to just start formula feeding rather than helping me.” — BellyBelly Facebook Fan
Medical Schools and Breastfeeding Education
Between February and May 2007, a 90-item questionnaire containing demographic, attitude, and knowledge items was distributed to final-year Australian GP registrars for a study. It was found that:
“… 40% of the knowledge items were answered incorrectly by the majority of participants. Approximately 40% of the cohort were confident and thought they were effective assisting breastfeeding women.”
Wendy Brodribb undertook a survey of all available medical schools for her PHD in 2005-2006.
“There is very little information about the amount of breastfeeding education for any of those groups, and no specific requirement. Now working in a medical school, I realise that many schools may not actually have any idea of how much is taught and when,” she says.
“As far as vocational training goes (i.e. GPs, obstetricians and paediatricians), they may have a curriculum outline, but that does not necessarily mean they have any formal education. I know that the RACGP (Royal Australian College of General Practitioners) and the ACRRM (Australian College of Rural and Remote Medicine) mention breastfeeding in their curriculum. While my survey results may now be out of date, I doubt whether there have been significant changes to the breastfeeding curriculum. There are often none or very few breastfeeding questions in the Diploma of Obstetrics and Gynaecology exam”.
Clinical Midwifery Consultant, Gwen Moody, said that the medical students she trains in New South Wales only receive one or two hours training.
“When I first starting presenting to medical students, I tried to do it in the allocated hour. It was impossible, so I asked for more time – 2 hours. In our unit, during their obstetric rotation, the medical students go out with the midwives who do home visits, so they see a lot of the women breastfeeding and the support required.”
Another consultant confided, “The medical students from UWA [University of Western Australia] have a 1 hour lecture in 5th year, and of that, 5 minutes is an about ABA spiel”.
As one of only three Victorian GP/IBCLCs, Dr Lisa Amir, said that GPs need to know how to manage common breastfeeding problems, such as sore nipples, mastitis and low milk supply. She also believes that one of the common issues is lack of understanding about safety of medicines for breastfeeding women.
“… in GP training, some people will receive education in breastfeeding, but others may not receive any. Medical schools need to recognise the importance of breastfeeding for maternal and infant health, as well as public health, and increase the teaching on this topic within medical courses”, Doctor Amir says.
A MOTHER SAYS: “I remember when I was struggling with breastfeeding, and my local doctor told me it was pointless after 3 months. He lost all credibility in my eyes after that.He had no idea why I was persevering. Still made it to 2.5 years, no thanks to him.” — Em Harris
A MOTHER SAYS: “I had a doctor tell me that breastfeeding [my daughter] past a year gave her no nutritional value.” — BellyBelly Facebook Fan
Ob/Gyns and Breastfeeding Education
Obstetricians are also in the first line of support for a brand new mother. Some mothers have personally confided that their obstetricians have given off the cuff advice to “just use formula – it's no big deal” if there are any issues. However, some obstetricians are quite concerned about the sad state of Australia's breastfeeding rates.
Professor Euan Wallace, Head of Obstetrics and Gynaecology at Monash University and Director of Obstetric Services at Monash Health says:
“Breastfeeding and breastfeeding problems are really important topics in the formal training of OGs [obstetrician gynaecologists]. Actually, the RANZCOG Members exam last year, I think, there was a whole question on breastfeeding reflecting the importance that it is (rightly) accorded. That said, the amount of formal education trainees receive will vary between training sites. At Monash Health, we provide dedicated sessions each year, but even then this will account for about 8 hours education in total (only).”
RANZCOG College President, Professor Michael Permezel, says, “The College believes that lactation and problems associated with breast feeding are important components of both the medical undergraduate curriculum and also postgraduate training in women's health for both GPs and specialists.
Most undergraduate curricula have lectures and tutorials. In some hospitals, the medical students are attached to the lactation support clinics. Postgraduate teaching is performed in the hospitals rather than lecture theatres or tutorial rooms. In the course of the everyday work of the O&G resident and registrar, breast feeding issues are managed on a daily basis by the doctors in collaboration with the midwives on the postnatal wards and in other areas of the hospital.”
Midwifery and Breastfeeding Education
Anna Russell, student midwife in New South Wales (who is 3 years into her 5 year part time course) says that the breastfeeding education has been, “the odd day or tutorial here and there so far. Extremely basic.”
In the Midwifery Accreditation Standards, breastfeeding is clearly stated under the minimum midwifery practice requirements:
“provision of care in the postnatal period up to four to six weeks following birth, including breastfeeding support.”
Sarah Stewart, Professional Officer at Australian College of Midwives explains that just like other medical professions, “Each university will have a different curriculum which means content and hours, clinical experience and assessment will vary from university to university.”
Maternal and Child Health Nurse and Education
Lael Ridgway is the co-ordinator of the Child Family and Community Nursing course at La Trobe University in Victoria. She says:
“Students in Victoria must be both registered nurses and midwives, so they already have a lot of lactation knowledge and practice. We embed breastfeeding promotion throughout the curriculum so it's difficult to quantify specifically.”
She continues, “Breastfeeding is covered more explicitly in two of the subjects in the Master of Nursing course, particularly from a public health and older child (4 weeks to toddlerhood) perspective, as this isn't included in the midwifery curriculum — and most midwives have little experience in these ages. We also cover management of the most common issues, referral options and alternate years include a speaker from the ABA (Australian Breastfeeding Association), but the education they start with is beyond the level ABA are able to provide in a session. They are encouraged to attend ABA meetings and seminars and can elect a breastfeeding clinic as one of their placements. Students who don't have recent breastfeeding experience are encouraged to do this.”
However, similarly to the above medical degrees, not all Australian states are the same. “Qualification for practice in Victoria is at graduate diploma level, but our course offers the option to progress to Master level. In other states, the nurses are not required to be midwives, so the need for breastfeeding education would be higher,” she says.
One Maternal and Child Health Nurse (with a Bachelor of Nursing, Graduate Diploma in Midwifery and a Postgraduate Diploma of Nursing Science in Child, Family and Community) who wishes to remain anonymous says there are problems that do need to be addressed. She says:
“In the maternal and child health course (taken in 2012), we did NO extra breastfeeding education on top of what we learned in the midwifery course (which was only a few hours at uni) and from professional development. It's a requirement at many hospitals that there is 2nd yearly breastfeeding education. Sadly, nothing enforces that it teaches the right things. For maternal and child health nurses (MCHNs) in Victoria, we have 2 conferences a year that covers various things, including at times, breastfeeding. We are encouraged to attend regular conferences etc to keep into up to date including breastfeeding conferences.”
But do professionals attend these conferences?
“Some midwives and MCHNs like myself are interested in breastfeeding and want to be up-to-date, so we pay and go to conferences. But so many are not interested at all.”
One problematic challenge for MCHNs is that they often have to self-fund to attend conferences, and take personal leave hours to attend. “Conferences are expensive enough, and when you're entitled to study leave and can't get it, it's annoying! We then have to pay to do it in our own time.”
She also said that while formula companies no longer sponsor Maternal and Child Health conferences, they do invite nurses to dinner education nights.
Another MCHN who trained in 2012 echoed the same sentiments. “I am unsure what the curriculum offers now, I know there is a difference between the two current training schools for MCHN in Victoria (La Trobe and RMIT). We got nothing on breastfeeding, however I am an LC [lactation consultant], and some MCHN's are.”
Enter The IBCLC
Those who decide to become lactation consultants do so because they are passionate about supporting new mothers to have a rewarding breastfeeding relationship (however long that may be).
An IBCLC is the person you should be see for breastfeeding advice and issues — especially when you feel that you may need formula. An IBCLC can correctly diagnose any issues, help you to rectify them and make sure your milk supply is protected. They will support you no matter if you choose to continue to breastfeed or use formula. Their personal preferences do not get in the way of professional advice.
Essentially, becoming an IBCLC is like obtaining a master’s degree in breastfeeding. When you compare the education and training of an IBCLC to that of a doctor or midwife, you really begin to see why there are major flaws in the system. While other professions are busy doing what they do best, IBCLCs are available to help you with what they do best.
Most IBCLCs already have a health degree — for example, a nurse or a midwife. If they want to become certified as an IBCLC, firstly, they must complete 90 hours of education in human lactation and breastfeeding. The required lactation-specific education must be completed within the 5 years immediately prior to applying for the IBLCE examination.
Within the 5 years immediately prior to applying for the examination, between 300-1000 hours of specific clinical breastfeeding experience needs to be undertaken.
Only once this criteria is met can you sit the IBLCE exam. Then you have to pass this challenging exam to obtain the credentials of an IBCLC.
IBCLCs are also required to re-certify with continuing education points (or re-sit the exam) every 5 years. They must re-sit the exam at least every 10 years – this helps them to maintain their up-to-date knowledge. For more information see the eligibility criteria here.
So to summarise, compared to 0-3 hours of basic breastfeeding information, an IBCLC:
- Usually has an undergraduate degree
- Must complete 90 hours of education in human lactation
- Must have 300-1000 hours of specific clinical breastfeeding experience (the number of hours required depends on the pathway being followed
- Must sit an intensive, rigourous IBLCE exam to qualify
- Must have ongoing education or re-sit the exam every 5 years
- Must re-sit the exam at least every 10 years
What stringent, ongoing requirements for a currently grossly under-utilised and undervalued profession! It's a shame that many other professions don't have the same requirements, keeping them up-to-date, ensuring they are giving the very best, current advice. There are professionals giving breastfeeding advice that is outdated and no longer recommended, yet there is nothing in place to check their knowledge or assess them to retain their qualifications.
Even the ABA's breastfeeding counsellors have much more training and education than you'd likely imagine. The hours required to complete a Certificate IV in Breastfeeding Education (counselling) to become a volunteer with the Australian Breastfeeding Association (who are an officially recognised training organisation) is 375-430 hours. They must attend at least one conference a year, as well as other ongoing training.
Is It Insanity?
They say the definition of insanity is to keep doing the same thing, while expecting different results.
I don't know about you, but to me, it seems like there is much assumption and expectation that medical professionals have enough prior experience or training to justify upping the amount of breastfeeding education. We need more.
You can't help but ask the question: is it any surprise that our breastfeeding rates have totally plummeted, when the standard care and support for breastfeeding women comes from health professionals with only around 2 hours of undergraduate education, if that? And, if healthcare providers are only receiving 0-2 hours of breastfeeding training and education, what are they basing their advice on? Could personal experience (if they even have children to begin with), marketing and bias come into play?
What we do know is that many new mothers seek advice, only to end up in a heap and/or switching to formula. You just have to browse any parenting community to see that top-up feeds and low supply assumptions and issues are at epidemic levels. It's created so much insecurity, guilt and stress. These parenting communities become a battleground any time infant feeding is discussed. It's become a huge physical, emotional and social mess — compliments of the gross misinformation and lack of education.
There are so many challenges, and one of the most difficult problems that educators — even BellyBelly — faces is educating about breastfeeding in a now heavily formula feeding population. Many formula feeding parents take offense to seeing breastfeeding education, even if there is zero judgement within the content. They see it as an attack on how they feed their babies. I would guarantee a big reason for this would be due to the fact that those mothers had a terrible experience with breastfeeding support themselves, leaving them resentful and unsupported.
Miranda Buck, IBCLC says, “There's always that annoying argument about not wanting to make women who can't breastfeed feel guilty. Yet we promote exercise to everybody regardless of the small number of paraplegics who can't even walk.”
Early education and appropriate professional support is so very important, and obviously not something enough new mothers are receiving.
Sadly, There Is A Big Professional Barrier
Another unfortunate layer of the breastfeeding onion that needs to be peeled off is the professional barrier going on between care providers.
Doctor Elizabeth Thomas is a paediatrician who sees two major issues. She says:
“Firstly, there is big fear among doctors that the ABA Helpline in particular (not so much LCs) will give anti-doctor advice and undermine the medical treatment of a sick baby. This is partly because of the push of alternative medicine in other areas (chiropractors and such) and ABA just gets caught up in it.”
“The second is simply access and awareness of local services. My hospital has an “in-house” lactation consultant service, so I mainly use that. At my hospital, everyone knows this is a good service. There is a bit of reluctance to use people or services who are unknown, I think. I used to work at Monash, and when I was there they didn't have a lactation clinic at all. They used to hand out the ABA Helpline card and that was it – women were on their own.”
A Maternal and Child Health Nurse said that she comes across a huge number of women where their paediatrician has advised to top up breastfed babies with formula, even for some who don't really need it (doing so will reduce a mother's milk supply). Another common piece of erroneous advice she hears often is to “pump and dump” breastmilk when a mother has mastitis, when it's best to keep feeding through it.
“Some paediatricians are juniors and have no idea about breastfeeding at all — often they have not had kids, so there's no factual or practical education on breastfeeding.”
A MOTHER SAYS: “I saw a doctor from my family doctors office for mastitis and he told me to pump and dump so that my son wouldn't be drinking milk with bacteria in it.” – BellyBelly Facebook Fan
A MOTHER SAYS: “I had mastitis when my bub was only a few weeks old, and an after-hours GP prescribed antibiotics. He then told me the antibiotics would make my baby sick, so I should put her on formula.”- BellyBelly Facebook Fan
Pinky McKay, a highly sought after IBCLC and parenting author says, “It's so sad to see too many mums who have reached out for help to the first port of call professionals, such as child health nurses or GPs, who haven't been skilled enough to address the underlying issues for infant feeding problems. I have seen so many mothers with unsettled young babies who have been told “you need to learn tired signs” and even (from a paediatrician to a mum of a 3 week old, who had a tight posterior tongue tie and couldn't attach and suck properly), “your baby has behavioural problems.”
But when the underlying feeding issues are addressed, the baby becomes settled and the mother's anxiety is alleviated.
Doctor Thomas makes an important distinction when speaking to mothers and doctors. “The point that I always make to mothers and my residents (i'm a teacher for paediatricians as well) is that doctors deal mostly with illness and disease. Diagnosis and management is what we are trained to manage. Breastfeeding is not (or not usually!) a pathological condition. Just as we would refer to a speech therapist or physiotherapist for specialist management and ongoing support of a condition — which is not improved with medical management — lactation consultants are the people doctors [should] call if there is a problem with the breastfeeding relationship.”
What Is The Answer?
Of course, it would be great if all expectant parents could attend the ABA's breastfeeding education classes for expectant parents. It runs over 3-4 hours (which is more education than some professionals may get), giving parents basic knowledge to start their breastfeeding journey. It would be even greater if this service had government funding, so every expectant mother and her partner could attend.
Every health professional has a very important, valuable role to play when caring for pregnant women, new mothers and babies. They all have their much needed place.
However, the most qualified person for a new mother to see for breastfeeding problems is a lactation consultant, ideally an IBCLC, who has worked hard to obtain the gold standard in lactation education and training.
Professor Euan Wallace would like to see a collaborative solution, where both student obstetrician gynaecologists and student midwives are trained together. He believes that working together would compliment both professions' strengths and weaknesses.
Sarah Stewart from the Australia College of Midwives agrees. “The ACM certainly welcomes health professionals working together to improve breast feeding rates. Midwives and obstetricians can work to improve breastfeeding rates by ongoing partnerships in research, implementing mother and baby-friendly policies and practices that encourage breastfeeding — such as skin-to-skin at birth — and supporting midwifery models of care, that support mothers in the community in the post natal period once they have been discharged from hospitals.”
We also desperately need to ramp up education and standardise what's being taught across the board. If any healthcare provider is giving advice at a critical, make or break time, they need more in-depth education, at least to effectively support common breastfeeding problems while protecting breastfeeding and milk supply. Adequate education will do this. One or two hours will not. Beyond this, care providers must be the ones doing the referring to breastfeeding experts.
Doctor Lisa Amir says, “It would help if clinicians with breastfeeding expertise were employed in academic positions to promote breastfeeding within medical schools. As well as improved student training, this would facilitate research and collaboration with other professionals to improve our understanding of lactation and breastfeeding, management of breastfeeding problems, and increase the duration of breastfeeding.”
Jessica Leonard from the Australian Breastfeeding Association says: “We would certainly love to see more health professionals who work with mothers and babies taking the opportunity to continue their professional development in the area of breastfeeding. We run annual seminars for health professionals that give professional development points, and have just introduced a Diploma of Breastfeeding Management, which is aimed at health professionals that work with mothers and babies.”
She adds, “Anecdotally, we certainly hear a lot of stories from mothers who would have benefited from being referred to a lactation consultant, in many cases a referral to a specialist is vital. When health professionals do not have specific knowledge or experience of a medical issue, it's a reasonable expectation that they consult with a specialist themselves, or refer their patient on, and work together as a team with a specialist.”
Most of all, we need to see healthcare providers proactively working in collaboration with IBCLCs, for quick and easy referral. Women also need to be given the Australian Breastfeeding Association's helpline for any queries in the meantime, or for emotional support while they get help.
To put things into perspective, our less developed neighbour, Indonesia, is running rings around our exclusive breastfeeding rate.
- Indonesia: 49% fully breastfed at 6 months of age
- Australia: 15% fully breastfed at 6 months of age
These figures are likely heavily influenced by the premature introduction of solids in the 4-6 month period, which skews the figures significantly. This is another area that is full of contention, but healthcare providers need to know that leading health organisations from around the world are unified on this issue — read more here.
In order to save our society from becoming a completely formula feeding nation, the time for all of us to act is NOW. You just need to take a look at the comparison of ingredients in breastmilk to see why this is such a significant issue.
On The Other Hand…
Even if healthcare providers are supportive of the breastfeeding relationship, they still might not know a great deal.
It seems around 90% of the time, new mothers either complain about the lack of good support, else really pushy breastfeeding support. It's not often in between. I'm curious if those who are pushy don't have enough education also. Perhaps they've adopted the outdated “breast is best” (it's not, it's simply the biological normal way to feed babies) spiel, only have basic information about breastfeeding, so they just push the message at all costs? More education would mean they are aware of challenges and how to effectively support women. There are still old school professionals in hospitals that were taught on the job and not at university. Because they aren't regularly assessed for their qualification, they are skilled, but they may not be up to date on research.
A MOTHER SAYS: “The hospital I gave birth to my kids in pushed breastfeeding so hard they wouldn't feed the mother hospital food if you weren't breastfeeding. Rooms were littered with “breast is best”. Informative on breastfeeding but nothing at all on alternatives for those who couldn't.” — BellyBelly Facebook fan (from the US).
A Final Message
To healthcare providers: will you step up to the plate? Not just for women of today, but for our children, and their children too? It's time to work together. We all want the same outcome — healthy mothers and babies –and there is plenty of work to go around for all of us. Together, we can change a generation. Is there a way you can help implement change in your workplace?
To the Australian government: IBCLCs MUST be fully or mostly covered by Medicare. This was actually a recommendation as a result of the Parliamentary Inquiry into Breastfeeding in 2007 (which I was a part of). Eight years… better late than never. Come on, it's not fair that new mothers (without an income) have to pay so much to get appropriate, qualified advice so they can put nutritious food in their babies mouths. The taxpayer funds will be easily returned due to happier and healthier babies and mothers in society. Oh, and plenty more breastfeeding centres staffed with IBCLCs would be prudent too.
To mothers and mothers-to-be: We're very lucky to have such resourceful healthcare providers in this country. Some healthcare providers genuinely care about breastfeeding, and seek to acquire additional knowledge so they can best support you. But until things change for breastfeeding, if you're unsure or not happy with the advice from a care provider and it's not an emergency, see a specialist. See an IBCLC. It's not a crime to seek a second opinion. But know that IBCLCs are not alternative practitioners. They are experts in their own right. You and your baby deserve the best.