ANTENATAL OBSTETRIC FACTORS
Preterm birth (as well as caesarean birth) are common end pathways of antenatal complications, either iatrogenic or spontaneous. Preterm delivery may be complicated by the mother/parent, 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/parent requires intensive care.
Human milk is extremely important for preterm babies. Many parents who planned to formula feed are motivated to provide expressed milk in the context of prematurity. The ability to provide human milk 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 those at high risk of preterm birth should focus on the importance of human milk, the potential challenges and how to mitigate these, particularly the need for urgent first expression after birth (within 2-4 hours).
Pre-eclampsia may be associated with preterm birth. The mother may be taking antihypertensive medication, but this is not a contraindication to breastfeeding/chestfeeding. 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/chestfeeding 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 participants 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 - parents should receive education antenatally on maximising breastfeeding/chestfeeding success for these babies.
Exclusive or predominant breastfeeding/chestfeeding rates are lower in the context of gestational diabetes, although initiation and rates of any breastfeeding/chestfeeding are not. This may be due to the way that the infant's risk of hypoglycaemia is managed (for example large volume supplements reducing breast stimulation through feeding), or mediated by intrapartum complications. Insulin resistance is associated with delayed lactogenesis II (milk 'coming in') in the context of type II diabetes, which may also be a factor.
Someone with gestational diabetes may be taking medication, such as metformin or insulin, frequently discontinued at birth. Breastfeeding/chestfeeding is likely to have a particularly high impact on these dyads, due to the association of breastfeeding/chestfeeding with improved cardiovascular health in the mother/parent, and reduced obesity in children.
Infants have a risk of neonatal hypoglycaemia - mothers/parents should receive education antenatally on maximising breastfeeding/chestfeeding 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/parents with gestational diabetes, with an increase in exclusive human milk feeding in the intervention group. Parental education in the waiting room of glucose tolerance testing and GDM clinics is a good way of efficiently accessing these mothers/parents!
This may be associated with preterm birth, particularly iatrogenic. The mother/parent may have been taking medication antenatally but this is usually discontinued at birth. There is no contraindication to breastfeeding/chestfeeding.
Babies from multiple births are less likely than singletons to receive any human milk at time points up to 6 months of age, with odds ratios of around 0.6 - and dramatically less likely to receive exclusive human milk with odds ratios of around 0.2. Sick and preterm multiples are more likely to receive any and exclusive human milk 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/chestfeeding 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/chestfeeding should still be encouraged and valued if parents don't want to exclusively breastfeed/chestfeed 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.