Friday, September 25, 2009

Recommended Reading: Empowering Mothers

Recommended Reading
Empowering Mothers
E Dawson, R Gauld and J Ridler say midwives need to abdicate control
Nursing RSA VERR{LEGING Vol 8 No 4 1993}

Ideally, lactation success depends on many factors: 
     A healthy mother with perfect nipples and a hungry eager baby; an informed supportive partner; an experienced, caring midwife with no time limits; clinic sisters and doctors knowledgeable in overcoming lactation problems; supportive, well-informed family and friends; how many of us know of this ideal situation?  What can and does go wrong?   Who can help?  Who has the time?  
     Over the last few years it’s been encouraging to see the increased awareness of the benefits of breast-feeding, but unfortunately breastfeeding practices and protocols have just not been kept up.   At a seminar on breastfeeding in Cape Town last year, 81% of the health professional present felt they did not have adequate know-ledge to help mothers breastfeed.  And a study by Professor Walter Loening and Jane Maasdorp of the University of Natal, found the level of knowledge among doctors and nurses of breastfeeding to be quite appalling!  
     While the need for the extensive education and training is obvious, let’s look at things from a different angle.  Let’s start by looking at these two statements: - 
* Breastfeeding is a confidence trick
* Breastfeeding is 95% psychological.  
95% of a mother’s ability to breastfeed is psychological – she must have confidence in herself. 
     In order to help a mother breastfeed, therefore, our first and major task is to instill confidence in the new mother.   How do we do this? 
     This depends on an understanding of cultural differences, lifestyle and background.  The assumption that all mothers are ill-formed about breastfeeding should not be made.  Some women accumulate a vast store of up-to-date knowledge during their pregnancy and all they need is lots of reassurance and encouragement.  
     She may or may not have planned her pregnancy, but in the majority of cases she has the desire to be a good mother to her child.  Respect her ability to make decisions that will affect herself, her baby and her family.  
     Communication skills are so important here.  Make use of such courses offered to you.  
     Breastfeeding is not usually a medical problem – it is a mothering concern.  A very emotive issue.  Sometimes health workers voice their own strong opinions, not facts.  Of course, we’re all entitled to our own opinions – so is the new mother.  Do her the courtesy of allowing her to make her own decisions and form her own opinions based on sound up-to-date facts.  It will do wonders for her self –esteem and confidence.  A new mother is smothered in other people’s opinions and receives much unsolicited advice from well-meaning friends and relatives.  The very best defense that she has to cope with is this confidence.  Confidence in her ability to nurture and nourish her baby and to meet his ever-changing needs.  
Give information and not advice. 
     This is not an easy thing to do initially.  What’s the difference between information and advice and why do we say this?   
     When we give advice we also send another unspoken message – a lack of confidence and trust in the woman.

We need to take a good 
look at our own attitudes.  
It is often painful to abdicate control.

Advice begins with phrases such as: - 
“You should…” 
“You ought to…” 
“You must…” 
“You should have…” 
     Even if the mother is open to receiving advice, the outcome is rarely positive.  The possible consequences are: 
~ If the mother follows the advice and is successful.  
   Result: She’s likely to become more dependent on the midwife rather than learning to trust herself and her baby. 
~ The mother follows the advice and fails.  
   Result: She has to face the consequences and the midwife loses credibility. 
~ The mother rejects the advice and is successful.  
   Result: She may also reject the midwife. 
~ The mother rejects the advice and fails. 
   Result: She may resent the midwife or elevate her, but feel diminished herself.  
     Giving information, on the other hand, implies trust.  The underlying assumption is that the other mother is capable of making her own choices.  Giving information, making suggestions, and presenting options conveys trust which is the basis of any helping situation.  Even though the midwife may have a greater wealth of knowledge and experience about breastfeeding, she needs to respect the mother’s ability to make her own decisions.  
Eg.  “How would you feel about…” 
“You might find that…” 
“Some babies seem to need…” 
“Recent research indicates…” 
     Discuss options and don’t forget to give positive strokes.  She is the expert on her baby as nobody will get to know her baby better than she will.  Tell her this.  The goal here is to empower the mother.  Give her facts she needs to make an informed decision and support her decision.  
     Explain to the mother how the breasts work - she will then be able to work many things out for herself. 
     Make the explanation simple without talking down to her.  Eg. You could explain that he breast is not like a bottle - it is not a container that is filled up and emptied.   
    Explain that what collects in the breast between feeds in the foremilk which is watery and quenches the baby’s thirst. Only once the milk ejection reflex has occurred in response to the baby’s suckling, does calorie-rich hind milk become available.  The breast is like a production site with the milk being made almost continuously – the quicker the product (i.e. the milk) is taken off the production line the quicker and more plentiful will be the production.  
     The majority of mothers today are breastfeeding when they leave the maternity unit, however, within a few weeks or sometimes even days, most of them switch to the bottle.  Why?  Insufficient milk supply, breast infections, embarrassment, fear of criticism from friends and relatives, and general confusion are some of the reasons given.  
     Women need to be prepared for the first few weeks.  With an understanding of what to expect during the first crucial weeks of adjustment it will be easier for her and many more women and their babies will enjoy the benefits of breastfeeding. 
     On leaving the hospital, new mother’s need to know a few important facts:  
     The golden rule of breastfeeding – the more the baby sucks, the more milk will be produced – a brief explanation of supply and demand.  
     Newborns need to be fed at least 10 to 12 times in 24 hours.  The stomach of a newborn is the size of a walnut and breast milk is digested in about an hour and a half.  
     A fussy time of day is normal for many babies – it’s not necessarily a sign that something is wrong.  
     At about 10 days many babies go through a growth spurt (and again at about 6 weeks and 3 months).  They appear to be hungry all the time and mothers begin to doubt their milk supply.  A day or so of feeding the baby more frequently will increase the milk supply very well. 

     An explanation of what to expect as regards to the baby’s stools is important – what they look like and the frequency – loose and frequent in the beginning, may change to only once a week later, etc.  
     Water and dummies are best avoided in the early weeks – they may cause nipple confusion and interference with the initiation and maintenance of the adequate milk supply.  
     Adjustment – The new mother should be encouraged to think of the first 6 to 12 weeks as an adjustment period – baby needs to be held close and fed often as he adapts to extra-uterine life and mom needs frequent breast stimulation to initiate and maintain a good milk supply.  The frequent close contact helps with bonding.  
     The mother needs to be cautioned about trying to be supermom. 
     Wet nappies – what goes in must come out!  In the exclusively breastfed baby, after the first 36 hours, 6 to 8 really wet nappies a day is a good and pretty reliable indication that the baby is getting enough.  
     Where to go for help - Remember that problems often arise after “clinic hours”.  Mothers need telephone numbers of  24-hour breastfeeding counselors.  
     This may sound all very nice and ideal – fine for a well-run, and well-staffed maternity unit.  But does it really take so much time?  A lot of patience is needed to help a mother breastfeed.  A lot of time is spent helping and encouraging her – it really doesn’t take too long to impart these few important points.  Or put them on a simple hand-out for each mother to take home with her.   

If we want to make each mother feel good about her mothering, and to feel in control, we need to take a good look at our own attitudes.
It is often painful to ab-dicate control.
So often a new mother is treated like a child herself and feels she has lost 
control of the situation.

Maureen Minchen, at her outspoken best, says, “If we don’t know what we are doing and why, then we shouldn’t be doing it.”  The sad fact is that some cases of lactation failure are iatrogenic.  Perhaps as important as all the technical information is the shaping of attitudes which give mothers their rightful place in child health strategies.  Protocols that truly support breastfeeding usually require breaking from tradition.  Such protocols include early first feeding at the breast, demand feeding at frequent intervals (at least 10 to 12 times in 24 hours), night feeding, rooming-in, and a knowledgeable, and supportive nursing staff.  Optimal newborn care is increasingly recognized as that in which the parents provide all the care for their newborn with minimal supervision.  This move to a patient-directed experience requires often painful abdication of control and is hindered by the subtle competition among adults for the care of an attractive newborn.  
     We are in a helping profession.  We want to help.  But sometimes we hinder.  Mother nature can manage with very little help most of the time.  Research by a Swedish pediatrician, Dr. Lennard Righard, showed that healthy newborn babies left with their mother for more than an hour before any procedures were undertaken, found their way to the breast and started nursing correctly for 20 minutes after birth.  The key to the matter lies in our attitudes to the newborn and his mother.  
     Now that sound, research-based information is readily available, the professional ignorance which may have been acceptable in the past is no longer acceptable.  
     We need to have extensive education and training in the art of breastfeeding, knowledge and skills in the techniques of breastfeeding, and an understanding of the psychological growth essential to a woman’s gaining confidence in her ability to mother her own infant.  

(References on file) 

This  is required reading for Ancient Art Midiwfery Institute’s Advanced Midwifery Studies.
There is so much food for thought here when preparing to be an authentic “with woman” midwife.

1 comment:

  1. A very good article Carla. As a Midwife, I have always offered "education" rather than "instruction" or "advice". I also never "helped" initiate breastfeeding or even suggested that it was "time" to get baby to latch etc. After birth, most motherbaby pairs find their own way to nursing in their own time. I leave them be and let them navigate their relationship on their own terms. My watch-phrase has always been "assume competence" and most of the time, I've found that this is warranted. There are, of course, always the occasions when more assertive "help" is truly needed and it requires discernment to know the difference between something needed by motherbaby/family and something needed by the Midwife in order to feel "useful"! I struggled with this more as a younger, less experienced Midwife when still trying to "prove myself to myself" as well as to clients. With time and experience, we gain wisdom and nearly 100% of the time, the labor/birth/bonding/breastfeeding continuum works as designed.