Informed Decision and the Proven Benefits of Breastfeeding

The question should never be "if" we discuss the benefits of breast milk feeding with a mother, but instead "how" we discuss the proven benefits of breastfeeding.   

If you are like me, one question I often asked was, “Do you plan to breastfeed or formula feed?” Whatever the mother chose was the extent of the conversation. I, by nature, am not confrontational. I never wanted a mom to feel less than supported if she decided to formula feed. Had I genuinely known the extent of the benefits to what seemed to be such a simplistic, straight-forward question, I would have approached the conversation differently. I can’t change the past, but I hope going forward I can help other clinicians feel confident aiding mothers and families to make an informed decision about nutrition for their baby. If I could go back, I would have started my conversation with mom (and other support person[s] if available) by stating, “I would like to discuss a few benefits of breast milk feeding for both you and your baby, so you feel confident making an informed decision about your feeding choice. Whatever decision is made, I am here to support you. And, of course if there are any additional questions, I am here to answer them.”

What is Informed Decision Making?

In past decades, there has been a shift from a paternalistic decision-making model, where the healthcare provider makes decisions for a client, to a model of informed decision-making, where a client makes a decision based on a clear appreciation and understanding of the facts, implications, and consequences of an action. This type of decision making empowers patients, builds relationships between healthcare professionals and their patients, and meets ethical requirements that could actually improve outcomes.

Why Informed Decision Making as it Relates to the Proven Benefits of Breastfeeding?

Regarding the benefits of breast milk, I cannot count the number of times I have heard mothers say things like “if I had only known,” “why didn’t anyone tell me?,” “if I would have known these benefits, I would have chosen to breastfeed,” and “I’m mad no one said anything”. Just last week, I was speaking about the proven benefits of breastfeeding to a group of non-clinicians. One woman who has two middle-school-aged children stood up and said, “WHY DIDN’T ANYONE TELL ME THIS WHEN I WAS PREGNANT?! This is fascinating!”. I couldn’t answer her question, but I assured her I was going to do my part to engage more clinicians, moms, and families about the immediate and long-term benefits of breast milk feeding. 

Many national (and international) organizations support breast milk feeding and informed decision-making.  It is everyone’s responsibility to help a mother make an informed decision.

The Surgeon General Supports Breastfeeding in a Call to Action

“Action 1:  Give mothers the support they need to breastfeed their babies. This includes, but is not limited to, helping pregnant women to learn about the importance of breastfeeding for their babies and themselves. All clinicians are responsible for this.”

The CDC National Survey - Maternity Practices in Infant Nutrition and Care (mPINC)

The CDC surveys eligible hospitals about every two years to assess maternity care practices. This feedback encourages hospitals to improve upon practices that better support breastfeeding. You can assess your state’s score here. Included are sub-scores that further categorize specific areas such as “frequency that staff counsel breastfeeding mothers who request infant formula about possible health consequences for their infant and the success of breastfeeding”.

IBCLE Code of Ethics

The IBCLE Code of Ethics includes a code of Professional Conduct Principles. Principle 1 is to “provide services that protect, promote and support breastfeeding.” Within this principle, it states that every IBCLC shall “supply sufficient and accurate information to enable clients to make informed decisions”.

Importance of Health Outcomes and Informed Decision

The American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and the World Health Organization (WHO) all recommend breastfeeding exclusively for the first six months of life, but why? There are many benefits to the baby, the mother, and society as a whole. Benefits to the baby include, but are not limited to:

• Antibodies that are highly protective
• Breast milk is easily digested
• Less otitis media
• Fewer gastrointestinal illnesses
• Fewer respiratory illnesses
• Decreased risk of SIDS
• Protective against some childhood lymphomas and leukemias
• Improves growth, intelligence, and development

Although small amounts, colostrum provides a bolus of highly protective antibodies. Think of colostrum as the baby’s first immunization. Colostrum also helps to seal the gut by making it less permeable to bacteria. This is critically important for preterm infants who are susceptible to many infections, especially necrotizing enterocolitis (NEC).

Benefits to the mother include, but are not limited to, decreased risk of:

• Breast cancer
• Ovarian cancer
• Type 2 diabetes
• High blood pressure

Breastfeeding and/or breast pumping can help reset the mother’s body back to its pre-pregnancy state, decreasing the metabolic and inflammatory changes happening postpartum. Sustained metabolic and inflammatory changes can increase the risk of cardiovascular, metabolic, and other diseases later in life.

The longer a mother breastfeeds, the more protection she is provided.

How to Provide Informed Consent Regarding Mom’s Decision to Provide Breast Milk or Formula

If you’re like me, it can be challenging to discuss the benefits of breast milk feeding if a mother elects to formula feed. If a mother chooses to provide formula after discussing the benefits of breast milk feeding, I can walk away with confidence, and without judgment, knowing she made an informed decision that was best for her and her situation. 

What may be helpful to assist a mother in making an informed decision is:

• Start by explaining that you will be supportive of whatever decision she makes
• Allow her to participate in the conversation
• Listen intently to her thoughts on infant feeding
• Provide evidence-based, unbiased information
• Ask open-ended questions such as, “tell me about your plans for feeding your baby?”

You may start by saying, “As one of your healthcare providers, I will support you as you make a decision about feeding your baby. It is important that you make a decision that works for you, your baby, and your situation. I want to be sure you have enough information to make an informed decision.” Or, “have you had the chance to discuss your feeding plans with anyone?”

Breast milk provides an enormous amount of benefits to baby, mother, and society as a whole. For this reason, it is critical that we, as clinicians, inform our patients about the benefits of breast milk feeding and the risks associated with not doing so. As with all other healthcare decisions, as long as the patient is able to participate in the discussion, they deserve to have the information to make an informed decision regarding what is best for their baby. After providing information, no matter the decision, it is also important that we support mom’s decision. 

I hope this challenges you, whether you are a bedside nurse, a physician, or a lactation consultant, to ensure all moms are able to make an informed decision about what type of nutrition to provide to their baby. Thank you for all that you do to support all moms and babies!

References

1. Shah P, Thornton I, Turrin D, et al. Informed Consent. [Updated 2021 Jun 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK430827/
2. AMA J Ethics. 2020;22(5):E423-429. doi: 10.1001/amajethics.2020.423.
3. Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women's Health (US). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011. A Call to Action. Available from: https://www.ncbi.nlm.nih.gov/books/NBK52691/
4. CDC. Maternity Practices in Infant Nutrition and Care (mPINC™) Survey | Breastfeeding | CDC, cdc.gov/breastfeeding/data/mpinc/index.htm. 
5. International Board of Lactation Consultant Examiners (IBCLE). (2015). Code of Professional Conduct for IBCLCs,  iblce.org/wp-content/uploads/2017/05/code-of-professional-conduct.pdf. 
6. CDC. Breastfeeding Benefits Both Baby and Mom, cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html. 
7. American Academy of Pediatrics (AAP).  Why Breastfeed, healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Why-Breastfeed.aspx. 
8. American Academy of Pediatrics (AAP).  Benefits of Breastfeeding for Mom,  healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Why-Breastfeed.aspx.
9. Informed Decision Making:  Having Meaningful Conversations Regarding Infant Feeding, breastfeedingresourcesontario.ca/sites/default/files/pdf/Res_Strategy_IDM_Toolkit_EN.pdf.
10. Goldberg H. Informed decision making in maternity care. J Perinat Educ. 2009;18(1):32-40. doi:10.1624/105812409X396219