Structural influences and barriers I Awenga ā-pūnaha, taero ā-pūnaha

Infant feeding decisions are influenced by the society and environment in which parents and caregivers live, and the level of support they are able to access to achieve their breastfeeding goals (Rollins et al 2016).

There is strong evidence for the positive benefits of skin-to-skin contact between parents and infants following birth. A Cochrane Review (Moore et al 2016) supports using immediate or early skin-to-skin care to promote and support breastfeeding.

Widström et al (2019) conducted observational research on infants immediately after their births to establish a more detailed analysis of the infant’s behavioural sequence that begins immediately after birth and ends with the infant latching at the breast, suckling and then falling asleep. This work expanded understanding of the beneficial practice of mother–infant skin-to-skin contact, provided significant evidence of the criticality of the period of time after birth, and demonstrated how easily the infant behavioural sequence could be derailed.

The nine behavioural phases are birth cry, relaxation, awakening, activity, crawling, resting, familiarisation, suckling and sleeping. Rest periods are interspersed with active stages, and during the rest periods the infant does not demonstrate rooting reflexes. These quiet and inactive pauses are to be expected and need to be protected. If the newborn infant is disturbed during the relaxation periods, this can further delay progress through the stages leading to latching and suckling (Widström et al 2019).

Because labour medications can affect the newborn feeding reflexes, medicated infants may demonstrate longer rest periods and take a longer time during the familiarisation stage. Evidence suggests that intrapartum exposure to the drugs fentanyl and synthetic oxytocin significantly decrease the likelihood of the baby suckling while skin-to-skin with the breastfeeding parent during the first hour after birth (Brimdyr et al 2015).

• Important Findings Published About Common Labor Medications and Breastfeeding Success
• The Magical Hour

Whānau and partners play a crucial role in breastfeeding. Research has shown that breastfeeding parents who have support from their partner, whānau and broader social network are more likely to initiate and continue breastfeeding (Foaese 2019; Fisher 2016). Nevertheless, health care and other providers do not always engage with partners and whānau very effectively. Studies in diverse global settings have demonstrated the benefit of engaging partners and whānau in the preparation and support process (Fisher 2016). A partner who is educated and able to provide support can be a key determinant of successful breastfeeding (Brown 2018). Familial infant-feeding traditions, along with advice and encouragement from mothers and other elders, can also have a positive effect on breastfeeding.

Social norms and attitudes do not always value breastfeeding. The sexualisation of breasts combined with a lack of breastfeeding visibility has meant breastfeeding in public can be difficult (Hahn-Holbrook 2018). Breastfeeding parents may face negative reactions from members of the public, or feel embarrassed and unconfident about feeding in public (Brown 2018). Additionally, there are many perceptions around the differences between formula-fed and breastfed infants. The belief that breastfed babies are less content, need to feed more often and will not sleep through the night may discourage breastfeeding. This is reinforced with the normalisation of formula, which has led to public perceptions of formula as normal, risk-free and a positive way for partners to participate in infant feeding (Brown 2018).

The relationship between socioeconomic status and breastfeeding initiation and duration has been shown in many studies. Research has identified a considerable socioeconomic gradient for initiation and duration of breastfeeding, with those most disadvantaged socioeconomically less likely to initiate breastfeeding and less likely to be breastfeeding at six months (Amir and Donath 2008; Keim et al 2019). Strategies aiming to increase the initiation and duration of breastfeeding need to pay heed to this, and address social and health inequities.

Cultural beliefs play a great role in shaping how breastfeeding parents perceive and experience breastfeeding. Moreover, religious and cultural beliefs shape perceptions of infant feeding, and certain beliefs may either constrain or enable breastfeeding (Brown 2018).

Perinatal distress is a common occurrence in Aotearoa New Zealand, experienced by between 15 to 25 percent of pregnant people and new parents (Deverick and Guiney 2016; Kendall-Tackett 2017). The relationship between mental wellbeing and breastfeeding can be multifaceted and complicated (Watkinson et al 2016).

Research shows that breastfeeding lowers the risk of depression and helps overcome past adversity (Kendall-Tackett 2017). However, the relationship between breastfeeding and postnatal depression and anxiety is variable, with both positive and negative effects recorded (Austin et al 2017; Borra et al 2015). For some, breastfeeding can help reduce the likelihood, severity or length of postnatal depression. For others it may cause stress and anxiety (Perinatal Anxiety and Depression Aotearoa 2020).

A small percentage of breastfeeding parents experience feelings of depression, anxiety, homesickness, agitation or anger, beginning immediately before their milk lets down (Cox 2010; Kendall-Tackett and Uvnas 2018). This is called Dysphoric Milk Ejection Reflex (D-MER). Symptoms of D-MER may decrease by three months postpartum or may continue throughout the breastfeeding period (Australian Breastfeeding Association 2018). D-MER is very different from postnatal depression or an anxiety disorder.

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Australian Breastfeeding Association. 2018. Dysphoric Milk Ejection Reflex (D-MER). Australian Breastfeeding Association. URL: https://www.breastfeeding.asn.au/bfinfo/dysphoric-milk-ejection-reflex-d-mer (accessed 19 September 2020).

Borra C, Iacovou M, Sevilla A. 2015. New evidence on breastfeeding and postpartum depression: The importance of understanding women's intentions. Maternal & Child Health Journal. 19(4): 897–907.

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Cox S. 2010. A case of dysphoric milk ejection reflex (D-MER). Breastfeeding Review. 18(1): 16–18.

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Foaese A. 2019. Māori and Pasifika women’s experiences of breastfeeding across the South Island Consumer stories: Quality Improvement Project. South Island Alliance.

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Hahn-Holbrook J. 2018. The psychological effects of breastfeeding. In Family Larsson-Rosenquist Foundation. Breastfeeding and Breast Milk—From Biochemistry to Impact: A Multidisciplinary Introduction. Stuttgart: Georg Thieme Verlag.

Keim S, Smith K, Ingol T, et al. 2019. Improved estimation of breastfeeding rates using a novel breastfeeding and milk expression survey. Breastfeeding Medicine. 14(7): 499–507.

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Kendall-Tackett K, Uvnas M. 2018. D-MER-Hypothesis grounded in previous research. Clinical Lactation. 9(3): 106–7.

Moore E, Bergman N, Anderson G, et al. 2016. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. Issue11. Art. No.:CD003519.

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Rollins N, Bhandari N, Hajeebhoy N, et al.  2016. Why invest, and what it will take to improve breastfeeding practices? The Lancet. 387(10017): 491–504.

Watkinson M, Murray C, Simpson J. 2016. Maternal experiences of embodied emotional sensations during breast feeding: An interpretative phenomenological analysis. Midwifery. 36: 53–60.

Widström A, Brimdyr K, Svensson K, et al. 2019. Skin-to-skin contact in the first hour after birth: underlying implications and clinical practice. Acta Paediatrica. 1192–1204.