Kathleen Kendall-Tackett, PhD, IBCLC, FAPA looks at the crisis in confidence revealed by a recent study that finds more pediatricians believe breastfeeding will fail than succeed.
A recent study of pediatricians in the U.S. examined their recommendations and beliefs regarding breastfeeding from 1995 to 2014 (Feldman-Winter et al., 2017). Over this period of time, pediatricians were more likely to recommend exclusive breastfeeding, and to indicate that their hospitals had applied for Baby-Friendly status. They also were more likely to recommend mothers return for a postpartum visit by 5 days. Yet, they were less likely to believe that mothers could successfully breastfeed, or that the benefits outweighed the risks. Further, only 47% referred mothers to community support groups and only 47% recommended avoiding pacifiers until breastfeeding is established. Pediatricians also felt less confident that they could manage breastfeeding problems.
These findings are ominous. Of all health care providers, mothers are most likely to turn to their pediatricians. These doctors are saying all the politically correct things. Yes, mothers should exclusively breastfeed. And yes, their hospitals should be baby-friendly. But if they believe that mothers cannot succeed, mothers will know this. It can come out subtly, as an off-hand remark or facial expression. They can suggest that the mothers try breastfeeding, implying that it probably won’t work. Or it may be more direct, with a quick use of supplements rather than trying to solve the problem.
Breastfeeding is largely a confidence game. As pediatrician Tina Smillie says, we must “ooze confidence” that breastfeeding will succeed. After birth, when women are flooded with oxytocin, they become particularly attuned to others, and as a result, vulnerable to criticism and subtle, non-verbal cues (Uvnäs-Moberg, 2015). If pediatricians don’t really believe that breastfeeding will work, it will come out—and mothers will sense it.
How did we get here? There are several factors that I believe have contributed to this crisis in confidence.
- Personal experience. If pediatricians had negative breastfeeding experiences (or their partners did), that may override all the things they have been told to say. Unfortunately, I’ve known many physicians who have had negative experiences. They run into the same lack of support most new mothers face AND they are expected to already know what to do. They become isolated and struggle alone. If they are in training, they may be expected back at work very shortly after birth, also making it likely that breastfeeding will fail. (One of our chief residents in pediatrics was already back at work at only 3 weeks postpartum.) If we want pediatricians to support breastfeeding, we must be kinder to them as new mothers.
- Lack of knowledge about what to do. When I’ve taught pediatric residents, they’ve admitted that they are in a tough position. People expect them to know how to handle breastfeeding problems, yet they’ve little to no training on what to do. When I’ve taught them, we have focused on how to spot problems and where to send the mothers for help. They don’t need to know everything a lactation consultant knows. They just need to know a lactation consultant to whom they can send mothers.
- Defensive medicine. There have been several high-profile cases where breastfeeding difficulties were not spotted, and babies ended up with serious health problems. From a litigation standpoint, it may feel safer for pediatricians to suggest formula than to solve the breastfeeding problem, especially if they don’t feel like they have the resources to support the mother.
- Misinformation from the formula companies. We need to remember that pediatrics became a specialty to help mothers choose the “right” formula for their babies. They’ve come a long way since then. But the formula companies are relentless and the bottle-feeding culture still influences what pediatricians are taught (e.g., the amount babies should eat and how often they should be fed). These subtle messages can also affect providers’ interactions with mothers.
Health care providers’ beliefs have a tremendous impact on patients, and we should be concerned when providers believe that breastfeeding is an unattainable goal. We can think about this when we look at research on the placebo effect. The placebo effect happens when providers are confident: patients believe that a treatment will work—and it does—even when they have received no active substance. This effect can also work the opposite way. If a provider expresses that a treatment will not work, patients’ beliefs can negate the effects of even powerful medications. This is called a nocebo effect. In this case, providers’ negative beliefs about breastfeeding become a nocebo and can undermine women’s confidence in their bodies’ ability to feed their babies.
Education continues to be important, and as more hospitals are seeking baby-friendly status, education is a mandatory part of the process. Physician-to-physician organizations, such as the Academy of Breastfeeding Medicine, are also an important means to educate physicians. At the local level, those of us working in the field of lactation can reach out to physicians in our communities, as many of you have already done. If they’ve had difficult breastfeeding experiences, we need to hear them, and then work with them on ways to make the situation better for other mothers. Systemic changes are important, but individual relationships are where we really change things for the better.
Keep up the good work you are doing. You are making a difference for the mothers in your community.
Feldman-Winter, L., Szucs, K., Milano, A., Gottschlich, E., Sisk, B., & Schanler, R. J. (2017). National trends in pediatricians’ practices and attitudes about breastfeeding: 1995 to 2014. Pediatrics, 140(4), e20171229. doi:10.1542/peds.2017-1229
Uvnäs-Moberg, K. (2015). Oxytocin: The biological guide to motherhood. Amarillo, TX: Praeclarus Press.
Kathleen Kendall-Tackett, PhD, IBCLC, FAPA
Dr. Kendall-Tackett is a health psychologist and International Board Certified Lactation Consultant, and the owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. She is Editor-in-Chief of two peer-reviewed journals: Clinical Lactation and Psychological Trauma. She is Fellow of the American Psychological Association in Health and Trauma Psychology, Past President of the APA Division of Trauma Psychology, and a member of the Board for the Advancement of Psychology in the Public Interest.
Dr. Kendall-Tackett specializes in women’s-health research including breastfeeding, depression, trauma, and health psychology, and has won many awards for her work including the 2016 Outstanding Service to the Field of Trauma Psychology from the American Psychological Association’s Division 56. She has authored more than 400 articles or chapters, and has recently completed her 35th book, The Phantom of the Opera: A Social History of the World’s Most Popular Musical. Her most recent books include: Depression in New Mothers, 3rd Edition (2016, Routledge UK, in press), Women’s Mental Health Across the Lifespan (2016, Routledge US, in press, with Lesia Ruglass), Psychology of Trauma 101 (2015, Springer, with Lesia Ruglass) and The Science of Mother-Infant Sleep (2014, Praeclarus, with Wendy Middlemiss).