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Infant Feeding

Labour, Birth and Early Postpartum Considerations

Although breastfeeding intention rates are very high, what happens during labour, birth and early postpartum can set the stage for infant feeding from initiation to six months and beyond. Policies and practices associated with infant feeding initiation include type of labour, epidural status, type of birth, skin-to-skin contact, and supplementation for hospitals. 1 Some of these policies and practices are also key performance indicators for hospitals.2

Interventions that support exclusive breastfeeding incorporate a combination of education, counselling and support and a seamless continuum of care between early postpartum and community care.3,4 Another critical practice that supports breastfeeding is reduce conflicting advice as much as possible.5,6

By influencing what happens during labour, birth and early postpartum, health care organizations and providers can influence breastfeeding rates.

Best practices to support infant feeding at birth and early postpartum are outlined in Steps 1 through 10 of the Baby-Friendly Initiative (BFI). 7 BFI7 also requires compliance with the International Code of Breast-milk Substitutes8 and outlines what this means for health care organizations.

Feeding Babies in Simcoe Muskoka: Labour, Birth and Early Postpartum Considerations Infographic

In Simcoe Muskoka:

  • Over 90% (92.3% [91.5%–93.0%]) of parents plan to breastfeed, including over 85% (86.6% [85.6%–87.5%]) who plan to breastfeed exclusively.9

At Birth:

  • Over 90% (92.0% [91.2% - 92.8%]) of babies are breastfed at birth, including approximately 70% (68.9% [67.5% - 70.2%]) of babies who are exclusively breastfed*.9
    • The decrease between exclusive breastfeeding intention (85%) and initiation (70%) indicates that many parents do not meet their exclusive breastfeeding goals within the first day of birth.
  • Rates of breastfeeding initiation and exclusive breastfeeding initiation from BORN differ somewhat from data reported by parents as part of the SMDHU Infant Feeding Surveillance system. 10
    • SMDHU IFS10 data show 92% (91.8% [88.5% - 94.2%]) of babies are breastfeeding at discharge from hospital (or within 48 hours after birth), including 64% (63.8% [58.8% - 68.5%]) of babies who are exclusively breastfeeding.
    • An additional 4% [4.2% [2.6% - 6.8%)] of babies who receive supplementation in hospital are fed only breastmilk by the time of discharge (however these babies cannot be categorized as exclusively breastfeeding).10

 Infant Feeding Intention and Intiation Rates SMDHU 2019

* There are two data sources for initiation data: SMDHU IFS and BORN. The exclusive initiation rates from SMDHU IFS differ from BORN. Reasons for these differences are explained on the SMDHU IFS data source page on the HealthSTATS website.

Supplementation:


Early postpartum:

  • Excusive breastfeeding rates continue to drop off in the first weeks after birth, with 45% continuing to exclusively breastfeed for two months.10

Labour and birth interventions impact the normal hormonal process of birth and may impact breastmilk production and readiness for breastfeeding initiation. Research has shown that when the onset of labour is spontaneous, maternal and fetal systems are aligned for optimal postpartum physiologic transitions, including breastfeeding initiation and maternal-newborn attachment. 11

Local data show the following labour and birth interventions are associated with lower rates of exclusive breastfeeding initiation:

  • Having an induced labour or no labour compared to spontaneous labour;
  • Having an epidural compared to not having one; and
  • Having a caesarean section compared to vaginal birth.9

 Exclusive Breastfeeding Intiation Rates by Labour Type Epidural Status and Birth Type SMDHU 2019 

  • Caesarean section is also independently associated (causal) with lower exclusive breastfeeding rates at two, four and up to six months.12,13

Duration of Exclusive Breastfeeding by Birth Type SMDHU 2017-2019

Skin-to-skin contact immediately after birth supports an infant’s adjustment after birth. It is a key strategy for breastfeeding initiation as the vast majority of newborns will go to the breast within an hour of birth if they are kept skin-to-skin with the breastfeeding parent. 3,14,15 Best practice recommendations related to skin-to-skin contact include supporting uninterrupted skin-to-skin contact immediately after birth for at least the first hour, or until completion of the first feeding or as long as the parent wishes.7

In Simcoe Muskoka:

  • Uninterrupted skin-to-skin contact for at least one hour within the first two hours after birth increased significantly from 19.3% (95% Confidence Interval: 18.1% - 20.5%) in 201416 to 54.6% (53.2% - 56.1%) in 2019.9
  • Skin-to-skin contact after birth is associated with exclusive breastfeeding initiation.9

Supplementation is the provision of any food or drink other than breastmilk received from the breast. Despite recommendations to the contrary, non-medically indicated supplementation is common.17 Healthcare professionals may recommend supplementation when it is not medically indicated as a means of protecting parents from fatigue or distress. 17 New parents, particularly those with low breastfeeding confidence, are vulnerable to advice suggesting breastfed infants be supplemented with glucose water or infant formula.17

Providing formula or other liquids to breastfed infants when not medically required may result in breastfeeding challenges including decreased breast stimulation, milk production and maternal confidence, and increased risk of delayed lactogenesis.18 Preventing unnecessary supplementation of breastmilk substitutes is also important as exclusive breastfeeding to six months protects the infant gut.19,20 Supplementation with infant formula is also associated with lower breastfeeding duration rates. 21,22,23 When supplementation occurs, wherever possible, it should be a short-term intervention with the goal to return the infant to feeding at the breast.21

In Simcoe Muskoka:

  • Approximately 30% (31.1% [29.8% - 90.7%])9 of babies are fed infant formula in the first few days after birth, including:
  • The prevalence of infant medical supplementation has more than doubled in the last five years, from 2.8% (2.3% - 3.3%) in 2014 16 to 7.4% (6.7% - 8.2%) in 2019.9 The reasons most commonly noted include “hypoglycemia”, “inadequate weight gain” or “significant weight loss in the presence of clinical indications”, and “other clinical indications”. 9
  • Breastfed babies fed infant formula in hospital have lower rates of breastfeeding at two, four and up to six months.12
 

Duration of Any Breastfeeding by Supplmentation with Formula in Hospital SMDHU 2017-2019

Regression analysis (to determine independent associations) of local data indicates parents in Simcoe Muskoka may need extra support to begin breastfeeding exclusively if they:

  • Live with an annual before-tax family income of less than $60,000;
  • Delivered their by c-section;
  • Gave birth preterm;
  • Are 35 years of age or older; and/or
  • Are a first time parent.9

Education, immigration status and marital status were also analyzed to assess association with breastfeeding rates and found to not be independently associated. Other social and economic factors such as housing status and access to support networks were not available for analysis however, literature suggests there are other factors (including underlying social and economic influences) associated with breastfeeding initiation including:

  • parent demographics (e.g. ethnicity, language, income);
  • parent health status (e.g. diabetes, hypertensive disorders); and
  • parent confidence, attitudes, knowledge and beliefs. 24,25,26

Populations with lower breastfeeding initiation rates may benefit from additional breastfeeding support in addition to support to address barriers to breastfeeding such as addressing challenges with food insecurity, lack of support networks or other social and economic factors.

Health care providers can also provide support by ensuring all parents know about infant feeding programs and services in the community and how to access them.

In Simcoe Muskoka:

  • The majority (90.3% [95% Confidence Interval: 86.8%–93.7%]) of new parents are aware of community programs and services to help with feeding their baby.27

Health care providers can:

1. Assess parents for barriers and risk factors that may impact how they start feeding their babies

This includes assessing:

  • Birth experience and interventions;
  • Breastfeeding knowledge, attitudes and beliefs;
  • Breastfeeding confidence/self-efficacy (including previous breastfeeding experience);
  • Available supports;
  • Pre-pregnancy body mass index;
  • Perinatal mood disorder;
  • Tobacco, alcohol and other substance use; and
  • Social and economic determinants of health (SDOH).
 

Clinical Resources:

 

2. Provide tailored education, counselling and support

Support parents to make informed decisions

  • Provide accurate and unbiased information about infant feeding, including:
  • National infant feeding recommendations;
  • The importance of breastfeeding;
  • The importance of exclusivity;
  • The risks of non-medically indicated supplementation;
  • The health risks of not breastfeeding for both parent and child;
  • The risks and costs of formula feeding.
  • The potential risks of using soothers.
  • Support parents to feed their babies
  • Educate parents who plan to breastfeed about position and latch, and how to tell if their baby is getting enough;
  • Educate parents who plan to breastfeed and formula-feed how to protect their breastmilk supply; and establish a plan with the parent for the ongoing management and evaluation of the supplementation; and
  • Educate and support parents who plan to provide any infant formula to:
  • choose a formula that is acceptable, feasible, affordable, sustainable, and safe (AFASS)
  • safely prepare, feed and store formula.
  • Encourage early skin-to-skin contact and breastfeeding
  • Support skin-to-skin contact immediately following birth and support skin-to-skin contact/breastfeeding during painful procedures (e.g. blood draws, immunizations).
  • Complete routine procedures (e.g. weights, measurements, eye ointment, and injections) following the first feed.
  • When separation of parent and baby is medically required, it is for the shortest possible duration.
  • Educate parents about:
  • The importance of early and ongoing skin-to-skin contact (including skin-to-skin contact/breastfeeding during painful procedures, e.g. blood draws, immunizations)
  • Hand expression
  • Cue-based feeding;
  • Ways to calm their babies;
  • The rights of breastfeeding parents;
  • Possible breastfeeding problems, their solutions; and
  • Available breastfeeding and infant care supports in the community.

Clinical Resources:

Patient Resources

Programs and Services


3. Refer parents to breastfeeding supports, postnatal classes/programs and community social supports

Health care organizations can:

1. Create an organizational environment supportive of breastfeeding


2. Collaborate with community partners to:

More local intrapartum/early postpartum data is available from SMDHU’s HealthSTATS webpages.

  • Labour and birth data (e.g. care provider and birth location, labour type, birth type, interventions)
  • Pregnancy outcomes (e.g. pregnancy rate, fertility rates, multiple birth rate, preterm birth rate, small and large for gestational age rate, infant mortality rate, stillbirth rate)
  • Parent characteristics (e.g. social determinants of health, parental age, and parity)
  1. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. 2016. Matern Child Nutr; 12(3):402-17.
  2. Maternal Newborn Dashboard – Key Performance Indicator Criterion Reference Guide v2.0. 2019. Available from: https://www.bornontario.ca/en/data/resources/Documents/Maternal-Newborn-Dashboard-Criterion-Reference-Guide-v2.0.1.pdf
  3. Kim SK, Park S, Oh J, Kim J, Ahn S. Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud. 2018; 80: 132-137
  4. Registered Nurses’ Association of Ontario (RNAO). Best Practice Guideline: Breastfeeding – Promoting and Supporting the Initiation, Exclusivity, and Continuation of Breastfeeding in Newborns, Infants and Young Children. 3rd ed. [Internet]. Toronto, ON. 2018. Available from: https://rnao.ca/bpg/guidelines/breastfeeding-promoting-and-supporting-initiation-exclusivity-and-continuation-breast
  5. MacVicar S, Kirkpatrick P. The effectiveness and maternal satisfaction of breast-feeding support for women from disadvantaged groups: a comprehensive systematic review. JBI Database of Systematic Reviews & Implementation Reports. 2014; 12(6), 420-476.
  6. Schmied V, Sheehan A, McCourt C, Dykes F, Beake S, Bick D. Women’s perceptions and experiences of breastfeeding support. Birth. 2011; 38(1) 49-60.
  7. Breastfeeding Committee for Canada. The BFI 10 Steps and WHO Code Outcome Indicators for Hospitals and Community Health Services. 2017. Available from: https://breastfeedingcanada.ca/wp-content/uploads/2020/03/Indicators-we2019-En.pdf
  8. World Health Organization. International Code of Marketing of Breast-milk Substitutes [Internet]. 1981. Geneva. Available from: https://www.who.int/nutrition/publications/code_english.pdf
  9. BORN, 2019
  10. SMDHU IFS, 2019
  11. Buckley SJ. Executive Summary of Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. J Perinat Educ. 2015; 24(3) 145-153.
  12. SMDHU IFS, 2017-2019
  13. Beake S, Bick D, Narracott C, Chang YS. Interventions for women who have a caesarean birth to increase uptake and duration of breastfeeding: A systematic review. Matern Child Nutr. 2017 Oct;13(4):e12390. doi: 10.1111/mcn.12390. Epub 2016 Nov 24. PMID: 27882659; PMCID: PMC6866035.
  14. Meedya S, Fernandez R, Fahy, K. Effect of educational and support interventions on long-term breastfeeding rates in primiparous women: a systematic review and meta-analysis. JBI Database System Rev Implement Rep. 2017; 15(9) 2307-2332.
  15. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2016. https://doi.org/10.1002/14651858.CD003519.pub4
  16. BORN, 2014
  17. Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C, and the Academy of Breastfeeding Medicine. ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017 [Internet]. 2017. Breastfeeding Medicine; 12 (3): 1-11. Available from: https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/3-supplementation-protocol-english.pdf
  18. Buckley, SJ. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. 2015. Childbirth Connection: A Program of the National Partnership for Women & Families. Washinton, DC.
  19. Baby-Friendly Initiative Strategy for Ontario. BFI Implementation Toolkit [Internet]. 2018. Available from: https://breastfeedingresourcesontario.ca/sites/default/files/pdf/Res_Strategy_BFI_ImplementationToolkit_EN_2018.pdf
  20. Ho NT, Li F, Lee-Sarwar KA, Tun HM, Brown BP, Pannaraj PS, Bender JM, Azad MB, Thompson AL, Weiss ST, Azcarate-Peril MA, Liyonjua AA, Kozyrskyj AL, Jaspan HB, Aldrovandi GM, Kuhn L. Meta-analysis of effects of exclusive breastfeeding on infant gut microbiota across populations. 2018. Nature Communications; 9:4169. DOI: 10.1038/s41467-018-06473-x
  21. Toronto Public Health. Breastfeeding Protocols for Health Care Providers [Internet]. 2013. Toronto, ON. Available from: https://www.toronto.ca/wp-content/uploads/2017/11/9102-tph-breastfeeding-protocols-1-to-21-complete-manual-2013.pdf
  22. Smith H. Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database of Systematic Reviews. 2016. https://doi.org/10.1002/14651858.CD006462.pub4
  23. SMDHU IFS, 2015-2019
  24. Best Start Resource Centre. Populations with Lower Rates of Breastfeeding: A Summary of Findings [Internet]. Toronto, ON. 2015. Available from: https://resources.beststart.org/wp-content/uploads/2018/12/B09-E.pdf
  25. Best Start Resource Centre. Targeted Support for Ontario Populations with Lower Rates of Breastfeeding: 2013-2016 [Internet]. Toronto, ON. 2017. Available from: https://resources.beststart.org/wp-content/uploads/2018/12/B32_E.pdf
  26. SMDHU IFS 2016

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