3.0 Pregnancy Care
Baby Friendly Step 3 and Point 3
Inform all pregnant women about the benefits and management of breastfeeding.
Australia: Point 3 - Inform women and their families about breastfeeding being the biologically normal way to feed a baby and about the risks associated with not breastfeeding
The prenatal discussion should cover
- the importance of exclusive breastfeeding for the first 6 months,
- the health associations of breastfeeding
- the risks of artificial feeding, and
- basic breastfeeding management.
Pregnant women of 32 weeks or more gestation should confirm that the health associations of breastfeeding and implications of not-breastfeeding have been discussed with them, including at least two of the following:
- infant nutrition,
- disease protection,
- maternal-infant bonding,
- health benefits to the mother, and
- that they have received no group education on the use of infant formula.
They should be able to describe at least two of the following breastfeeding management topics:
- importance of rooming-in,
- importance of feeding on demand,
- how to assure enough milk, and
- positioning and attachment.

I want to know everything!
© Trisku

Workbook Activity 3.1
Complete Activity 3.1 in your workbook.
Some of these topics we've already covered, the remainder will be covered in following modules. Review the Topic 1.3 Relative Risks to ensure that you are confident to talk to mothers about risks of artificial feeding as well as the 'benefits' of breastfeeding.
Broaching the topic
Consider how you would continue the discussion following the mother's reply to the following questions.
Health worker: | How are you going to feed your baby? |
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Mother: | I'm going to bottle feed. |
OR
Health worker: | Are you going to breastfeed? |
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Mother: | Yes. |
These are closed questions and don't allow you to broaden the discussion without it being challenging to the mother, regardless of her response.
Health worker: | What are your thoughts on breastfeeding? |
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This open question will give you the opportunity to discuss any barriers that the woman may see to breastfeeding, or to discuss problems she may have had with previous breastfeeding and to begin discussion of the topics listed above.
It is also implicit in the question and following conversation that you consider breastfeeding to be relevant. The importance of the health care provider's attitude is significant when we find that a woman's attitude to breastfeeding has been shown to correspond closely to that of her health care provider. 2
Discussing breastfeeding with pregnant women needn't take more than a few minutes at each visit. For example, at the first visit...
Health worker: | What changes have you noticed in your body so far? |
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Mother: | My breasts have grown so much. I need to buy new bras! What's causing that? |
Health worker: | Your breasts are preparing themselves for breastfeeding your baby, growing extra milk-making ducts. Look, here's a diagram of what is happening inside your breasts. |
At this point you could give her some more information on how her breasts will make and release her breastmilk according to how often her baby feeds. In just a few minutes you've covered how to assure enough milk and importance of feeding on demand, without it becoming a 'lecture' for the mother.
A little bit of information given like this at each visit normalises breastfeeding as a part of childbearing and motherhood. At a later visit, closer to 32 weeks when you feel you've gradually covered all the information necessary and answered any questions raised, you could spend more time confirming the mother's understanding of breastfeeding.

Audit tool
Does your clinic have a method that records that all the topics listed above have been discussed with all pregnant women? If not, a sample checklist is available from Baby Friendly UK. Clicking on the icon to the left will take you to their checklist. Another sample checklist, developed by WHO/UNICEF is available by clicking here.

Don't force a premature, un-informed decision
Many health units ask the pregnant mother what her feeding intention is early in pregnancy prior to providing education.
It is not reasonable to expect anyone to make an informed decision without information.
Once the mother has given an answer, particularly if she chose artificial feeding, education about breastfeeding is frequently withheld.
Think about the impact such a simple question, asked at the wrong time, could have.
Do you really need to ask her at all? After she's learned about normal birth and cesarean delivery do you ask her which one she will have? Why not? Why should it be different with infant feeding?
When the mother does not breastfeed
- Infant conditions:
- classic galactosemia
- maple syrup urine disease
- Mother:
- cytotoxic chemotherapy
- addicted to illegal drugs
- HIV positive, when safer alternatives are available for her infant
- radio-active iodine-131 precludes breastfeeding for about 2 months. This should be avoided given that safer alternatives are available.

One-on-one education about the preparation of artificial feeds is to be given at the time of need.
- Other conditions may require the mother to temporarily withhold her breastmilk, or the infant to receive only limited amounts of breastmilk in conjunction with a specialized formulation.
- some maternal medications; most medications have alternatives that are safe during lactation
- very low birth-weight or very preterm infants
- infants with phenylketonuria; with careful monitoring
- infants with hypoglycemia that does not respond to breastfeeding or breastmilk feeding; though due to the seriousness of this condition intravenous therapy is preferred management.
A mother may also choose not to breastfeed for reasons of her own. It is important that the mother receives the education already mentioned and is aware of the short- and long-term effects of artificial milks on her child before she makes this decision.
Breastmilk substitutes
The choice of a breastmilk substitute should be made in conjunction with a pediatrician or other health professional who will have responsibility for the infant's health and growth. Factors such as a family history of allergies, weight gain issues and feeding difficulties with other siblings will guide this choice and the choice of feeding implements. The mother should bring these with her to the hospital or clinic so that she can learn how to prepare them and feed her infant while being supervised.
A large American study reported more than 3/4 of mothers using breastmilk substitutes did not receive instruction on formula preparation or storage from a health professional. 3
A systematic review of the literature from the United Kingdom described errors in reconstitution of breastmilk substitutes by parents, with a tendency to over-concentrate feeds, though under-concentration also occurred. 4
Infants fed a breastmilk substitute that is not prepared in a safe manner are prone to:
- hypernatremic dehydration,
- malnutrition,
- obesity, and
- gastrointestinal infections. 5
Because of the frequency and seriousness of these errors, instruction on formula preparation, storage and safe feeding practices must be given individually to the parents by a health professional at the time they need it . This teaching is not effective when given prenatally. Topic 7.5.4 details how to teach this skill.
The WHO Code on the Marketing of Breastmilk Substitutes precludes group instruction of this important skill. Likewise it stipulates that instruction is to occur after the infant is born, at the time of need. 6
What should I remember?

- Step 3 (BFHI) and Point 3 (Plan for the Community)
- the 3 important breastfeeding knowledge areas which must be covered with all pregnant women
- using open questioning and conversation techniques which can open discussion about infant feeding
- when breastfeeding is contraindicated
- when artificially-feeding parents are to receive instruction on infant formula preparation
Skills Competency #1

Communicating with pregnant women about infant feeding
Notes
- # World Health Organisation et al. (1992) Global Criteria fort he Baby-Friendly Hospital Initiative
- # Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey
- # Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.
- # Renfrew MJ et al. (2003) Formula feed preparation: helping reduce the risks; a systematic review.
- # Egemen A et al. (2002) A generally neglected threat in infant nutrition: incorrect preparation of infant formulae.
- # World Health Organization (2008) The International Code of Marketing of Breast-Milk Substitutes: frequently asked questions. Updated version 2008