Article written by Dr Susan Tawia, Manager, Breastfeeding Information and Research team, for the December 2014 health professional member eNewsletter.
A recent Italian study (Zuppa et al 2014) looked at the effect of neonatal care — partial vs full rooming-in — on the rates of breastfeeding in a group of mothers who had received epidurals compared to mothers who had not received epidurals.
What they found was that full rooming-in had a positive effect on breastfeeding rates. If babies roomed-in fully with their mothers, the rates of exclusive or predominant breastfeeding in the hospital were no different between mothers who had (91.7%) or hadn’t received epidurals (92.8%).
In contrast, if babies partially roomed-in with their mothers, then exclusive or predominant breastfeeding rates were lower in the group of mothers who had received an epidural compared with those that hadn’t received an epidural (59.2% vs 44.1%, p<0.001). Artificial feeding rates were high in all babies who partially roomed-in with their mothers.
This study clearly demonstrates that the type of care an infant receives in the hospital has the potential to overcome the adverse effects of epidural analgesia on the newborn.
Active management of third stage labour: oxytocin and ergometrine
Mothers in the UK who had a vaginal birth were survey about the use of uterotonics during the third stage of their labour, breastfeeding at birth, breastfeeding duration and, if relevant, the reasons they stopped breastfeeding (Brown & Jordan 2014). Uterotonics such as oxytocin and ergometrine were administered for postpartum haemorrhage prophylaxis.
At birth, no association was found between the injection of uterotonics and the way an infant was fed — breastmilk or artificial baby milk. However, at 2 and 6 weeks, mothers injected with uterotonics were significantly less likely to be breastfeeding at all. This group of mothers were also significantly more likely to report having stopped breastfeeding for physical reasons such as pain or difficulty.
The authors conclude that the injection of uterotonics appears to reduce breastfeeding duration, but not initiation. These data add to the growing body of evidence that active management of the third stage of labour may result in decreased breastfeeding rates.
A very large systematic review with meta-analysis, designed to determine breastfeeding rates after caesarean births (CB) compared with vaginal births (VB), was published in 2012. The review included 53 studies of 554,568 participants in 33 countries (Prior et al 2012).
Prior and her colleagues found that compared to women who gave birth vaginally, rates of early breastfeeding — initiation or at hospital discharge — were:
- significantly lower in the group of women who gave birth by caesarean
- significantly lower in women who gave birth by caesarean without going into labour (elective caesarean)
- the same in women who went into labour, but then gave birth by caesarean (Table 1).
Additionally, Prior and her colleagues found that overall rates of full/exclusive breastfeeding at 6 months were lower in women who gave birth by caesarean. However, of those women who initiated breastfeeding, there was no difference in the rates of full/exclusive breastfeeding at 6 months between women who delivered by caesarean compared with those who delivered vaginally.
Breastfeeding rates were lower in women who gave birth by caesarean without going into labour compared to women who gave birth vaginally. This comprehensive review of good-quality studies revealed that the difference is due to a decrease in early breastfeeding rates, not to a difference once breastfeeding is established.
To improve the breastfeeding rates of women who give birth by elective caesarean:
- both women and health professionals should be informed about the negative effect of elective caesareans on early breastfeeding rates
- all mothers should be encouraged and supported to initiate breastfeeding early.
Table 1. Odd ratios for breastfeeding amongst women who gave birth vaginally and by caesarean with and without labor.
|Odds ratio||95% Confidence interval||P value|
|Early breastfeeding initiation or at hospital discharge|
|CB vs VB||0.57||0.50, 0.64||p<0.00001|
|Prelabour CB vs VB||0.83||0.80, 0.86||p<0.00001|
|In-labour CB vs VB||1.00||0.97, 1.04||p=0.86|
|Any breastfeeding at 6 months
CB vs VB
|Any breastfeeding at 6 months in women who initiated breastfeeding
CB vs VB
|Full/exclusive breastfeeding at 6 months
CB vs VB
|Full/exclusive breastfeeding at 6 months in women who initiated breastfeeding
CB vs VB
Brown, A., & Jordan, S. (2014). Active management of the third stage of labor may reduce breastfeeding duration due to pain and physical complications. Breastfeeding Medicine, 9(10), 1-9.
Prior, E., Santhakumaran, S., Gale, C., Philipps, L. H., Modi, N., & Hyde, M. J. (2012). Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature, American Journal of Clinical Nutrition, ajcn-030254.
Zuppa, A. A., Alighieri, G., Riccardi, R., Cavani, M., Iafisco, A., Cota, F., & Romagnoli, C. (2014). Epidural analgesia, neonatal care and breastfeeding, Italian Journal of Pediatrics, 40(1), 82.