Informed Decision: How it Can Help Breastfeeding Outcomes

Promoting and protecting breastfeeding is critically important for infants of all ages and the American Academy of Pediatrics (AAP) recommends that infants are exclusively breastfed for first 6 months of life. However, the CDC reports on the U.S. breastfeeding rate indicate that only 58.3% of infants are meeting the goal. I would like to shine a light on one thing that we as healthcare professionals can do to promote and protect breastfeeding and the value of human milk. Although there are many interventions, I believe this one can have a significant impact helping mothers to reach the recommendation by AAP and their own breastfeeding goals: Providing informative and effective information so that families can make an informed decision on feeding practices for their baby.

What is Informed Decision and How Does it Help Breastfeeding Outcomes?

Being informed is more than just asking, “what do you plan to feed your baby?” Informed decision is about providing information as a way to educate families, so they can make the best decision. Oftentimes, special education and guidance about specific risks and benefits are required. This is also referred to as shared decision making with their provider.

Diane L. Spatz, PhD, RN-BC, FAAN reported on this early on in 2004 as the first step in her world-renowned paper titled Ten Steps for Promoting and Protecting Breastfeeding for Vulnerable Infants. It all starts with informed decision, which means all women should be educated about the benefits of breastfeeding and providing human milk to their infants. Unfortunately, many women and families are not knowledgeable about the risks associated with not breastfeeding.  This is especially important for women with a known high-risk pregnancy or at-risk conditions (such as primiparity, maternal obesity, diabetes, or hypertension), and these women especially should receive special education and guidance specific to the benefits of human milk and how to get the best start for lactation after delivery. Teach mothers and families about the specific components of human milk that can help protect infants. The protection in human milk is from the live white blood cells that assist with fighting infection, along with immunoglobulin A, lactoferrin oligosaccharides, lysozyme, and growth factors.

Dr. Spatz goes on to say that nurses have a responsibility to serve as patient advisors. I would go a little further by adding that all healthcare providers “have the responsibility to serve as patient advisors, informing families about why human milk is important for babies and especially vulnerable infants, and should be the standard of nursing practice.”

When you think about informed decision, it is a lot like informed consent. Informed consent guidelines apply primarily to a surgical or medical procedure, right? Basic information should be provided in informed consent, including the nature of the procedure, risks, benefits, and available alternatives. When you are getting ready for surgery and the medical team ask for you to give consent for a procedure, the provider then reviews the procedure and asks if you understand what is going to happen, if you have any questions, and, if there are none, then you sign. Your signature provides agreement, permission for the provider, the care, treatment, or service that is the subject of the consent.

Informed decision is when a person is given options to choose from several choices and educated on the benefits, risks, and expected outcomes of each. Similar to the key elements of informed consent (i.e. when a person agrees or gives permission or consent to a test or treatment they have been offered), informed decision helps parents fully understand the benefits, risks, alternatives, and outcomes of what is being offered when it comes to their newborn’s feeding options.

I recently read an article by The Joint Commission (TJC), titled “Informed Consent: More than just getting a signature”. Although the article addressed challenges with obtaining informed consent, the information easily applies to informed decision. In the report, they point out that one of the primary reasons there are challenges is because of “focusing on obtaining the patients signature as documentation of informed consent results in varying effectiveness of the communication between a clinician and a patient.” In other words, it is the process of communication and TJC refer to the process as “an essential aspect of patient-centered care and central to patient safety.” The same applies in the process of informed decision making. Instead of just asking the question about feeding choice and whether the mom intends to feed her newborn with breast milk or formula, it is more so about communicating the benefits and risks.

There are many barriers that contribute to a lack of understanding the information provided for informed consent and informed decision making. I will mention two key barriers:

• Ineffective provider-patient communication and lack of shared decision making between the patient and provider. Effective and clear communication and shared decision making has been shown to improve the adequacy of the informed consent process, and the capacity to enhance patient and family trust.
• Lack of consideration of patient cultural issues when developing informed consent communication forms and other materials. Cultural sensitivity and working through any language barriers is vital to obtaining informed consent. Make sure the patient and family understands the medical terms – Do not assume that they do, and avoid using medical jargon. Instead, use everyday language that they are more likely to fully understand.

The Importance and Long-Lasting Benefits of Informed Decision

In 2018, Dr. Spatz, PhD, RN-BC, FAAN writes on the importance of families making informed infant feeding decisions. In article she states that it is not enough for families to just know that breastfeeding is good; it is “essential” that they are fully educated on the science of human milk, and the dose dependent-nature of human milk and breastfeeding on health outcomes. The benefits not only include reduced mortality; instead, there are a number of morbidities that are significantly improved, including sudden infant death, necrotizing enterocolitis, sepsis, otitis media, lower and upper respiratory tract infections, and RSV. Even greater benefits have been documented for preterm infants (born before 30 weeks of gestation) fed more than 50% human milk during the neonatal intensive care unit stay, including increased white matter, brain size, and higher IQ.

Dr. Spatz, PhD, RN-BC, FAAN encourages healthcare providers to support families after they have made an informed decision to breastfeed by providing appropriate anticipatory guidance and realistic expectations about the first few weeks of breastfeeding. Early anticipatory guidance should include a detailed prenatal lactation risk assessment to help families understand all risk factors that may influence development of milk supply and goal setting.

It is sincerely my hope that all mothers have the opportunity to receive detailed information in order to make an informed decision, increasing their likelihood of choosing breast milk because it is the best choice for their baby and the preferred feeding for all infants. The above points will help healthcare professionals like ourselves support all women to make a confident, informed infant feeding choice.

References

1. Centers for Disease Control and Prevention. Breastfeeding report card: United States, 2020. Retrieved March 12, 2021 from  Breastfeeding Report Card United States, 2020 (cdc.gov)
2. Spatz, DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Perinatal Neonatal Nurs. 2004.
3. The Joint Commission, Division of Health Care Improvement.  Informed consent: More than getting a signature. February 2016. Issue 21. quick_safety_issue_twenty-one_february_2016pdf.pdf (jointcommission.org)
4. Spatz, DL. Helping mothers reach personal breastfeeding goals. Nurs Clin N Am. 2018;53:253-261.