Educating and Training Medical Professionals

Influence of Government and Health Authorities

Action on the part of health authorities to promote, protect, and support breastfeeding was a necessary component in promoting breastfeeding education for health care providers. In some countries, such action preceded public efforts to regain breastfeeding for mothers and infants. For example, Brazil’s National Breastfeeding Program (PNBF) began in 1981 in response to declining breastfeeding rates after rapid urbanization. The program created policy-level changes, including a provider education requirement following the Baby Friendly Hospital Initiative (BFHI) ¹ guidelines. Brazil now has some of the highest breastfeeding rates in the world. In contrast, in the US government efforts began well after rates increased through grass-roots efforts of women and groups such as La Leche League, founded in 1956. ²

In 1979 a joint meeting was held by the World Health Organization and United Nations International Children’s Emergency Fund (UNICEF) on Infant and Young Child Feeding. One of the central themes discussed was the education and training of health care professionals. ³ The 1984 Surgeon General’s Workshop on Breastfeeding and Human Lactation was the first US national meeting to focus exclusively on breastfeeding, and it outlined six major areas of need, one of which was the education of health care professionals. Since that time, all major health care organizations have agreed that educational institutions should be held accountable for professional training and that such accountability is essential to training professionals who are able to effectively support breastfeeding. Nevertheless, it has been an ongoing struggle to instantiate. Although many professional organizations describe requisite breastfeeding knowledge and skills for their fields, there are no consistent standards in medical education on breastfeeding and human lactation, except in midwifery. ⁴ In other words, it remains unclear how and when providers should obtain this necessary information. It should also come as no surprise that women who are cared for by midwives have the highest rates of breastfeeding initiation and duration. ⁵ , ⁶

Providers Who Breastfeed

Many physicians rely on experience with their own children in providing breastfeeding support. ⁷ These providers acknowledge that their medical training on breastfeeding is inadequate. It has been shown that personal experiences influence the type and quality of advice that is given. For instance, if providers had a negative experience, they may be more likely to recommend formula during the return to work period. Unfortunately, it is common for health care workers to have challenging breastfeeding experiences; this is especially true for physicians. One study of health care workers in Nigeria found knowledge, support, and practice of exclusive breastfeeding to be suboptimal. In this study, exclusive breastfeeding was more common among nonphysicians who had good knowledge of the benefits. ⁸

A provider’s own breastfeeding experience may be most at risk during the years of intensive training, because of the high workload, stress, and long hours. For instance, the American Academy of Pediatrics (AAP) Section on Medical Students, Residents, and Fellowship Trainees found that 75% to 92% of resident physicians encounter difficulties with breastfeeding and about one third do not meet their breastfeeding goals. ⁹ , ¹⁰ Negative emotions in such studies are common and are reported to affect clinical interactions with patients. Residents reported feeling “frustrated,” “depressed,” and “devastated.” ¹¹

In one study in Lebanon, medical trainees were found to have low breastfeeding knowledge and self-efficacy, with a poor professional network of support. ¹² In response to similar findings in the United States, in 2009 a group of physician mothers started their own grassroots support group, Dr. MILK (Mothers Interested in Lactation Knowledge), ¹³ and have since leveraged social media to support each other in their particular struggles to breastfeed while carrying on a professional career. This Facebook group has been used by over 20,000 physician mothers for this purpose and continues to grow.

Inadequate Training

In medical education, at least, information on breastfeeding tends to be left for the clinical years, during which time a student may or may not have adequate exposure, depending on patient census or teacher preference. ¹⁴ Thereafter, learning is relegated to optional continuing education courses. Because few board questions address breastfeeding management problems, few providers will seek out this education on their own. The AAP developed an online curriculum that has been shown to improve breastfeeding outcomes of patients when cared for by trained pediatricians. ¹⁵ Unfortunately, it continues to be implemented only if passion of the local teaching staff exists. No central unified program has been developed to change the curriculum at the seats of learning: medical and nursing schools.

Providers Left Out of Decision-Making

Because of the inability of untrained physicians and providers to adequately support breastfeeding, many families seek help elsewhere. There exists, in some communities, robust lay support in the form of extended family, mother groups, lactation groups, La Leche League groups, doulas, peer counselors, mother-to-mother informal milk sharing, and home visiting programs. For management of suck dysfunction and ankyloglossia, dentists, speech language pathologists, occupational therapists, chiropractors and massage therapists may also be assisting families. Such a rich tapestry of supports has the potential to broaden and deepen our knowledge of appropriate breastfeeding support, if coordinated and collegial. Unfortunately, providers without breastfeeding education are likely left out of these discussions. In areas that lack these other supports, it is possible families will have no support at all.

Faculty Leadership and Board Questions

It has long been a concern that medical or nursing students educated on lactation exclusively by lay providers may fail to understand the impact of lactation on their own scope of practice. In contrast, professional curricula have been developed and instantiated by passionate faculty leaders. Unfortunately, such a reliance on individual passion may or may not lead to sustainable change. Rather, to provide future generations with adequate knowledge, board certification examinations must test learners on breastfeeding knowledge suitable to their field(s). In response, schools will ensure their curricular adequacy. Additionally, robust breastfeeding support at affiliated training centers at the nursing, lactation consultant, and provider levels is critical to expose learners to appropriate care and offer opportunities for hands-on learning. It is no longer acceptable for academic centers to lack evidence-based breastfeeding support for patients and learners, from a clinical or educational standpoint.

Interprofessional Education

Interprofessional education refers to the education and training of health care providers in groups combining professions usually taught in silo: medical, nursing, dental, etc. It has been shown that educating in this manner can improve provider and patient satisfaction, ¹⁸ and it is gradually becoming incorporated into medical professional education. In breastfeeding education, it may help to emphasize the importance of the topic to learners and allow for an enriched understanding of scope of practice. Various groups of providers can learn ownership of their field’s management and support skills, while gaining knowledge of other fields’ contributions.

Motivational Interviewing

Patient-centered communication has been shown to promote behavior change and has been widely implemented in graduate medical education. ¹⁹ Several feasibility studies using motivational interviewing for breastfeeding have demonstrated a high patient and provider acceptance rate and cost-effectiveness. A small randomized controlled trial in the United States demonstrated improvement in breastfeeding duration after a motivational interviewing-based intervention. ²⁰ Because this technique has its origins in Euro-American psychology, its applicability in cultures that deemphasize patient participation in health care decision making must not be assumed. Indeed, using motivational interviewing in some circumstances may increase anxiety. A systematic review in Canada sought to determine its applicability in other ethnicities and cultures. ²¹ This review noted particular challenges in Chinese patients, and the need for cultural acknowledgment as part of counseling.

Trauma-Informed Care

Traumatic events affect health care by altering a patient’s response thresholds in light of prior vulnerability. That is, a patient’s behavior may be unpredictable based on the known medical history, if that history does not include facts related to prior trauma (such as ACES screening for Adverse Childhood Events Screening). A health care worker may therefore inadvertently worsen a patient’s condition by disregarding potential triggers or responding inappropriately to patient defensiveness, aggressiveness or silence. The occurrence of posttraumatic stress disorder after birth has been long neglected, but has now been shown to occur in 3.3% to 18.5% of postpartum patients, depending on background risks. ²² Acknowledging the globally estimated 35% of women who experience rape or intimate partner physical or sexual violence in their lifetimes, ²³ breastfeeding women are, therefore, likely to have had experiences of trauma. Breastfeeding itself carries significant stressors in terms of autonomy risk, pain, vulnerability concerns, and effort. ²⁴

Trauma-informed care refers to delivery systems that recognize the role of trauma in lifelong health and seek to provide care that traumatized patients experience as safe. The education of health care providers on breastfeeding should therefore include the tenets of trauma-informed care: screening for prior traumatic events (e.g., with ACES), minimizing distress and maximizing autonomy, and developing trusting relationships with patients. ²⁵ Other considerations may include listening to birth stories and validating feelings and screening for depression in postpartum patients.