Breastfeeding Support and the American College of Obstetricians and Gynecologists
by Anne Eglash MD, IBCLC, FABM
In October 2018, ACOG’s Breastfeeding Expert Work Group Committee on Obstetric Practice updated their February 2016 Committee Opinion on Optimizing Support for Breastfeeding as Part of Obstetric Practice.
ACOG’s 2016 Opinion on breastfeeding support was the first update since 2007, and was welcomed by breastfeeding supporters.
Both the 2016 and 2018 Opinions discuss the need for obstetrical providers to receive breastfeeding education in order to provide appropriate health care for breastfeeding issues. In addition, ACOG recommends that obstetricians help pregnant families make informed decisions on infant feeding by discussing the benefits of breastfeeding and sharing the few contraindications. Prenatal care should include attention to breastfeeding education and screening for risk factors that may lead to breastfeeding problems. Obstetrical providers need to integrate the World Health Organization’s 10 Steps to Successful Breastfeeding for birthing facilities into their clinical practice. In addition, breastfeeding women should be able to rely on their obstetrical providers for breastfeeding support and management of clinical breastfeeding problems in the outpatient setting.
- A recommendation that breastfeeding is an option for women who have undergone double mastectomy and reconstruction, by using a feeding device at the breast.
- Exclusive breastfeeding is recommended for the first 6 months of life, with continuation of breastfeeding when complementary foods are introduced during the infant’s first year of life, or longer, as mutually desired by the woman and her infant.
- The American College of Obstetricians and Gynecologists endorses the Centers for Disease Control and Prevention’s Evidence-based medical eligibility criteria for contraception use. (This includes the use of immediate postpartum contraception and combined birth control after 6 weeks postpartum.)
- The 2018 statement includes information on the components of safe positioning for the newborn while skin to skin.
- Initiation of milk expression within 6 hours of a preterm birth is associated with improved milk production.
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As reproductive health experts and advocates for women’s health who work in conjunction with other obstetric and pediatric health care providers, obstetrician–gynecologists are uniquely positioned to enable women to achieve their infant feeding goals. Maternity care policies and practices that support breastfeeding are improving nationally; however, more work is needed to ensure all women receive optimal breastfeeding support during prenatal care, during their maternity stay, and after the birth occurs. Enabling women to breastfeed is a public health priority because, on a population level, interruption of lactation is associated with adverse health outcomes for the woman and her child, including higher maternal risks of breast cancer, ovarian cancer, diabetes, hypertension, and heart disease, and greater infant risks of infectious disease, sudden infant death syndrome, and metabolic disease. Contraindications to breastfeeding are few. Most medications and vaccinations are safe for use during breastfeeding, with few exceptions. Breastfeeding confers medical, economic, societal, and environmental advantages; however, each woman is uniquely qualified to make an informed decision surrounding infant feeding. Obstetrician–gynecologists and other obstetric care providers should discuss the medical and nonmedical benefits of breastfeeding with women and families. Because lactation is an integral part of reproductive physiology, all obstetrician–gynecologists and other obstetric care providers should develop and maintain skills in anticipatory guidance, support for normal breastfeeding physiology, and management of common complications of lactation. Obstetrician–gynecologists and other obstetric care providers should support women and encourage policies that enable women to integrate breastfeeding into their daily lives and in the workplace. This Committee Opinion has been revised to include additional guidance for obstetrician–gynecologists and other obstetric care providers to better enable women in unique circumstances to achieve their breastfeeding goals.
The 2018 statement has additional information on ways to support breastfeeding women by providing more specifics on clinical management. For example, under the prenatal care section, there is information on supporting breastfeeding among breast cancer survivors, and evidence regarding the safety of breastfeeding during pregnancy. The intrapartum care section explains the evidence for rooming-in postpartum, and how to prevent sudden unexpected postnatal collapse for newborns. The Opinion gives special attention to health disparity, particularly the lower breastfeeding rates and higher prematurity rates among African American women. The importance of donor milk is mentioned in the 2018 opinion, but not at all in the 2016 opinion. Both statements mention that mothers should express their milk within 6 hours after a preterm birth to optimize milk supply. This is old data, and newer data suggests that milk volumes may be even higher if expression starts within the first hour postpartum.
It appears that the 2018 Opinion more solidly supports the Center for Disease Control’s eligibility criteria for contraceptive use as compared to the 2016 statement, especially regarding immediate postpartum use of progestin-only contraception, stating that there is a preponderance of evidence that there is no negative effect on actual breastfeeding outcomes. From my clinical experience, I am not convinced that we have the best evidence to conclude that harm will not be done to some women who are given progestins immediately postpartum.
Overall the 2018 Opinion appears more comprehensive as compared to 2016, and it will hopefully convince some obstetrical providers to enhance their central role in addressing breastfeeding issues during all stages of care. I am especially excited that pregnant women who are breastfeeding will have this document to share with obstetrical providers who still recommend weaning for low risk women.