ANTENATAL OBSTETRIC FACTORS
Preterm birth (as well as caesarean delivery) are common end pathways of antenatal complications, either iatrogenic or spontaneous. Preterm delivery may be complicated by the mother, baby or both being very unwell and may result in them being separated, for example if the baby is admitted to the neonatal unit or the mother requires intensive care.
Breastmilk is extremely important for preterm babies. Many mothers who planned to formula feed are motivated to provide expressed milk in the context of prematurity. The ability to provide breastmilk is often empowering and a source of pride, but the demands of expressing place a high burden physically and emotionally and concern over milk supply is very common. See separate pages for how to maximise the likelihood of success on the neonatal unit and for late preterm babies. Antenatal education for mothers at high risk of preterm birth should focus on the importance of breastmilk, the potential challenges and how to mitigate these, particularly the need for urgent first expression after birth (within 2 hours).
Pre-eclampsia may be associated with preterm birth. The mother may be taking antihypertensive medication, but this is not a contraindication to breastfeeding. Individual medicines can be checked using expert sources of information on medication in lactation. There is little evidence on whether pre-eclampsia negatively affects breastfeeding when preterm birth, caesarean section and postnatal need for intensive care is accounted for. A randomised trial of antenatal colostrum harvesting in pre-eclampsia is ongoing and this may offer benefit when started at 37 weeks, with mothers reporting satisfaction.
Beta blockers in the third trimester are associated with neonatal hypoglycaemia so in most hospitals these babies will be managed on a 'risk of hypoglycaemia' pathway - mothers should receive education antenatally on maximising breastfeeding success for these babies.
Exclusive or predominant breastfeeding rates are lower in mothers with gestational diabetes, although initiation and rates of any breastfeeding are not. This may be due to the way that the infant's risk of hypoglycaemia is managed, or mediated by intrapartum complications.
A mother with gestational diabetes may be taking medication, such as metformin or insulin, frequently discontinued at birth. Breastfeeding is likely to have a particularly high impact on these dyads, due to the association of breastfeeding with improved cardiovascular health in mothers, and reduced obesity in children.
Infants have a risk of neonatal hypoglycaemia - mothers should receive education antenatally on maximising breastfeeding success. Some units encourage antenatal expression of milk from 36 weeks to provide immediately available colostrum after birth - this has been shown to be safe in low risk mothers with gestational diabetes, with an increase in exclusive breastmilk feeding in the intervention group. Maternal education in the waiting room of glucose tolerance testing and GDM clinics is a good way of efficiently accessing these mothers!
This may be associated with preterm birth, particularly iatrogenic. The mother may have been taking medication antenatally but this is usually discontinued at birth. There is no contraindication to breastfeeding.
Babies from multiple births are less likely than singletons to receive any breastmilk at time points up to 6 months of age, with odds ratios of around 0.6 - and dramatically less likely to receive exclusive breastmilk with odds ratios of around 0.2. Sick and preterm multiples are more likely to receive any and exclusive breastmilk than well multiples. Mothers of multiples are more likely to give reasons such as 'takes too long', 'tiring' and 'time burden' when stopping breastfeeding, than mothers of singletons.
The Multiple Birth Foundation has a useful evidence-based guide for feeding in multiple birth. Antenatal preparation and intensive breastfeeding support will help to increase success and maintain the family's confidence. Preterm birth is much more likely in multiple pregnancy so the pages on the neonatal unit and late preterm birth are likely to be helpful. Exclusive breastfeeding of triplets or quads is possible, but will require significant practical on the ground support from family, friends or organisations such as Home Start volunteers. Partial breastfeeding should still be encouraged and valued if parents don't want to exclusively breastfeed multiple babies.
Assisted conception is associated with reduced breastfeeding rates, possibly mediated by increased rate of caesarean section. Theoretically there could be an impact of disturbed hormonal regulation as well.