ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding

Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Background

BREASTFEEDING IS THE BIOLOGICAL NORM and early weaning carries considerable maternal (1), and infant health (1) risks, and considerable social costs worldwide (1). The care that mother and infant receive in the first postpartum days will influence their future breastfeeding success (2), health, and lives (1). To improve this care globally, the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) launched the Baby-Friendly Hospital Initiative (BFHI) in 1991, which has since been revised twice. After 27 years, it has been implemented globally ; significantly improved infant health (1); and increased initiation, duration, and exclusivity of breastfeeding (1). The BFHI is considered the gold standard of evidence-based policy for maternity facilities that has been endorsed by different international organizations. However, breastfeeding disparities associated with social and structural determinants of health are still widespread (1). These result in unequal rates of morbidity and mortality, and health injustice for women and children (1). But, inequities may be reduced by implementing evidence-based maternity practices to support breastfeeding such as, BFHI (1), one-to-one continuous support during labor and birth, culturally sensitive care (M) or peer support (1) among others.

Purpose

Perinatal care practices influence delivery method, affect breastfeeding and maternal and infant health (1) (2) (H) and impact mother’s satisfaction (H). Thus, breastfeeding policies cannot be isolated from policies of maternity care as a whole. The purpose of this Protocol is to offer a “Model Maternity Policy Supportive of Breastfeeding,” which includes an “Infant Feeding Policy.” The term “Infant Feeding Policy” rather than “Breastfeeding Policy” is used as a step forward recognizing breastfeeding as the norm; it is inclusive (ensuring adequate support for parents feeding with supplements, exclusively with breast milk substitutes, exclusively with expressed breast milk, or chestfeeding in transgender individuals). It is also the language used in the updated 2018 WHO Ten Steps ( Table 1 ).

We have only included statements that are based on evidence or global recommendations in this document, which is intended to be a model for facilities seeking to implement high-quality perinatal care. It will need to be adapted to each specific institution, for example by including the name of the institution, and the date of revision, and follow each facility’s institutional process for approval and implementation. We are aware that some of the recommendations listed here may need to be adapted to the specific situations of each country (e.g., a country lacking midwives may have other type of providers attending normal deliveries).

This protocol includes all the elements covered by the BFHI “Global Criteria,” because the BFHI is, at present, the best model with proven efficacy. Some countries’ national Baby-Friendly accreditation standards may be more or less stringent than Global Criteria and those described herein. Thus, this model policy may require minor changes to conform to specific country requirements. This protocol will not address some specific requirements related to neonatal units, for which thorough recommendations have been published.

About the 2018 Policy Protocol

This comprehensive protocol encompasses contents of many other ABM Protocols: #1 (Guideline for Hypoglycemia), #2 ‘‘(Going Home), #3 (Supplementary Feedings in the Full-Term Neonate), #5 (Peripartum Breastfeeding Management), #8 (Milk Storage Information for Home Use for Full-Term Neonates), #10 (Breastfeeding the Late Preterm and Early Term Infant), #14 (Breastfeeding-friendly Physician’s Office), #19 (Breastfeeding Promotion in the Prenatal Setting), #21 (Guidelines for Breastfeeding and Substance Use or Substance Use Disorder), #26 (Persistent Pain with Breastfeeding), and 28# (Peripartum Analgesia for the Breastfeeding Mother).

A thorough scientific literature review (including recent statements/guidelines was conducted in PubMed and LILACS. The search included documents in English, Spanish, French, and Portuguese published between 2011 and 2018. More than 1,000 abstracts were reviewed, those of low quality were discarded and a final total of 302 articles were analyzed in full. Quantitative evidence was rated according to the 2011 Oxford Center for Evidence-Based Medicine criteria: Levels of evidence are graded from (1) to (5) according to this criteria. Qualitative evidence was graded using GRADECERQual: H (HIGH), M (MODERATE), L (LOW), VL (VERY LOW). All citations grouped before a given level of evidence share that level of evidence. Expert or international guidelines, including ABM protocols, are not assigned levels of evidence, and certain research studies do not fall into the level of evidence categories.

We acknowledge that partners of birthing individuals may be of any gender. Also, although the vast majority of birthing individuals are women, we acknowledge that transgender men and nonbinary-gendered individuals may also give birth and many may want to breastfeed or feed at the chest (chestfeed). Some transgender female to male individuals who have undergone surgery to remove all or some of the breast parenchyma to achieve a flat chest wall may report variable experiences with milk production. They may wish to feed at the chest through supplemental devices or breastfeed, or conversely, some transgender parents may feel uncomfortable with the idea of breastfeeding or chestfeeding (M) (VL). Throughout this document, we may refer interchangeably to “mothers,” “birthing individuals,” or “parents.”

We recognize that adopted newborns and their adoptive parents (5), and infants born to surrogate mothers and their nonpuerperal mothers/parents (5) equally need to bond and have the right for help with infant feeding (breastfeeding if chosen) and therefore are included in the words “mothers,” “parents,” and “infants.”

Hereafter, the term “formula” refers to any kind of infant formula or breast milk substitute, including follow-up or any kind of “special formula.”

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