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Introduction
Pregnancy, birth and the postnatal period is a time of significant personal, emotional, psychological and social change for women and their partners as they transition to becoming parents [1]. The first 6-8 weeks after having a baby can be the most wonderful, exciting and happy times in the lives of parents, and this is how it is most often portrayed in the media.
However for many, the physical and psychological consequences of pregnancy and childbirth, the dawning reality of the momentous change in their social lives, as well as the change in the way in which they view themselves and each other, can have a significant impact on their health, their relationship with each other and with their baby (1, 2, 3).
The Public Health Nurse (PHN) is most often the first health professional that an Irish mother and her partner will meet when she comes home from hospital with their baby. According to the HSE (4), the role of the PHN is to visit homes following birth notifications and to monitor child, maternal and family health, and to particularly focus on the benefits of breast-feeding.
The World Health Organisation (5) recommends that babies be exclusively breastfed for 6 months, with continued breastfeeding along with appropriate complementary foods for up to 2 years and beyond. According to the Health Service Executive (6) 63.8% of Irish mothers initiate breastfeeding in our Maternity Units. This falls to 37.3% breastfeeding exclusively on the day of discharge from hospital, and 26.1% non-exclusively breastfeeding. Therefore, by the time the PHN see’s many of these mothers usually between day 2 and day 7, one quarter will be combination feeding, and many more may have stopped breastfeeding, or are having significant issues. The role of the PHN is to provide support, guidance and advice, and refer families to the appropriate healthcare professionals, should more specialised care and advice be needed.
The Role of the PHN
During the primary visit, one of the most important roles of the PHN for breastfeeding support is active listening. Before any paperwork is taken out or physical checks are completed, it is so important to ask the woman about her experience and how she is feeling. You can tell a lot about how these women are coping by just sitting, listening and watching her body language, eye contact, physical movements and emotional state. Asking open questions that invite her to tell her story, and repeating back to her important observations that help her feel heard and understood will help her debrief and feel more relaxed. When mothers feel more relaxed, their babies tend to be more relaxed, and feeding issues can be more easily resolved.
The PHN will then perform a top to toe assessment of the newborn, and a maternal health check. He/she will then observe a full breastfeed (with the mothers consent), and use the Breastfeeding Observation Assessment Tool (BOAT) to help recognise and address any breastfeeding issues (7). She/he will provide advice to parents with regard to care of the newborn, infant feeding, sleeping, core development etc.
The Scope of the PHN within Breastfeeding Support
PHN’s are generalists, who refer clients to the relevant healthcare practitioners depending on the area of need. PHN’s cannot be specialists in all of the areas that they cover i.e. wound care, child health, breastfeeding support, frail older adults, child welfare etc. Some PHN’s develop interests in certain areas such as wound care or breastfeeding, and may choose to educate him/herself further in this area. Public Health Nurses do a 20 hour breastfeeding education course as well as a Maternal and Child Health Nursing Module as part of their training (8), and they have access to the HSEland modules on breastfeeding also. This does not mean that PHN’s are breastfeeding specialists and can solve every issue, but they do have a lot of knowledge that may or may not be enough to help a breastfeeding mother in crisis. Therefore if PHN’s encounter a parent who is having difficulties, and feel it is beyond their scope, they should make sure to know who to refer to. The following is a list of services that the PHN should have knowledge of in his/her area:
The Area Lactation PHN
A PCCC can be sent to the Lactation PHN who covers your area. This PHN is a Lactation Consultant who has a high level of expertise with regards to all aspects of breastfeeding. Unfortunately, for a mother in crisis, she may not get an in-person appointment when she urgently needs it, as these PHN’s usually work in a centralised location that covers a large geographical area. However, a telephone call may be sufficient in some cases or an online consultation. In some areas there may be more Lactation PHN’s available than others, but it’s good to know your referral pathway, for when you or the mother you are working with needs support.
Hospital Lactation Consultant
Hospital-based Lactation Consultants are providing some fantastic services for women both antenatally and postnatally, from running free Breastfeeding Preparation Workshops to providing postnatal outpatient style clinics for 6 weeks postnatally. As with all services however, they vary depending on where you live.
Voluntary Organisations
Cuidiu Ireland and La Leche League have breastfeeding counsellors all over Ireland that provide free telephone support. Visit https://www.cuidiu.ie/ and https://www.lalecheleagueireland.com/ for further information. They are an excellent resource for new mothers, as well as a trusted support service for the PHN to refer families to. They also run weekly Breastfeeding Support Groups online (pre-Covid-19 these were in person), as well as conferences on breastfeeding, and have fantastic published material. “The Womanly Art of Breastfeeding”, by La Leche League is still one of the core texts for breastfeeding mothers and professionals alike, and one that I frequently read through.
Private Lactation Consultations
If parents wish to have a private Lactation Consultant, you can direct them to https://www.alcireland.ie/find-a-consultant/ where there is a list of current Lactation Consultant’s who are available all over Ireland. I personally believe there needs to be greater communication between the private Lactation Consultant, Public Health Nurse and GP, in order to create a more cohesive care plan and shared learning, but this ultimately comes down to parental consent for such communication, and some parents don’t wish for their L.C. to discuss their consultation with their GP or PHN, which is their choice.
Local Breastfeeding Support Groups
Pre-Covid-19, there were many local breastfeeding support groups around Ireland. I believe there should be a support group in every town in Ireland, in order to recreate that lost generational knowledge and support within communities. However, since Covid- 19, many support groups have moved online including my own (Latching On Facebook Group, which is a source of information for breastfeeding/combination feeding mothers and healthcare professionals who are interested in supporting these families). The HSE also have weekly support groups which can be run by PHN’s, Hospital Lactation Consultants, or Community Lactation Consultants, depending on where you live. Find out what is available in your area, and give this information to the mothers you meet.
Details for the local Baby-Wearing Library
Baby wearing is probably one of the most important (but less discussed) subjects to inform parents about, especially if they are breastfeeding, and especially if they have other children. Firstly, babies who are worn cry less and are generally calmer. They also tend to suffer from less gastro-intenstinal issues as they are in an upright supported position. If you think about it, the baby is close to their parent at all times, can smell and feel them, and can feel their warmth and heartbeat. Babywearing is excellent for both parents to feel connected with their baby, and for their baby to feel connected with them. The added bonus is that both hands are free and mum or dad can tend to other tasks such as making a well-deserved cuppa. Also once, baby gets used to the sling, they can also feed whilst in it, making feeding on the go possible. Parents should be directed to https://www.babywearingireland.ie/ , where they can find information on the Facebook group, rental libraries, and get expert advice from baby wearing consultants who can help them choose the right sling for them and fit it properly and safely.
Local Craniosacral Therapists
Craniosacral Therapy is a light-touch hands-on technique that can be effective in treating physical and biomechanical causes of tension and pain. It encourages the body to release restrictions that it is unable to overcome on its own (9). It is particularly helpful for babies with a torticollis (tight neck) who may be having feeding difficulties on one side, or for babies who have been breech or had a traumatic birth. CST can also be very helpful for babies who have an oral restriction such as tongue tie or asymmetric jaw.
Online Resources/Websites
Dr Google is a very dangerous place for new parents. The PHN should direct them towards Online forums that have Breastfeeding Counsellors or L.C’s as administrators, and towards trusted online resources such as www.hse.ie, www.friendsofbreastfeeding.ie, www.breastfedbabies.org, www.alcireland.ie, www.kellymom.com, and www.breastfeedingnetwork.org.uk. The HSE My Child books and online resources are also an excellent source of information (10).
Conclusion
I meet women every day who set out to breastfeed, but find themselves in a position whereby their plans do not come to fruition, for so many reasons. For some women/baby’s, breastfeeding is relatively easy and with a few tips they will go on to have a wonderful journey. However for many Irish mothers breastfeeding is hugely challenging, overwhelming and ultimately all-consuming. Covid 19 has brought new challenges to the mix also. In-person breastfeeding support groups have stopped. Some have moved online, and while it is wonderful to have these facilities there are many women who do not feel comfortable with this medium, and they are certainly no substitute for in-person support.
Public Health Nurses provide an invaluable service to the family’s of Ireland. The level of knowledge and expertise required to care for the postnatal mother, her baby, and partner is extremely high. PHN’s are incredibly passionate about providing the very best of care to our clients, but they cannot be all things to all people. This is why it is so important that PHN’s are aware of the services that are available to them and the families they serve, in order to enable and empower each mother who chooses to breastfeed to be able to do so.
“Breastfeeding is a mother’s gift to herself, her baby, and the earth”
Pamela K. Wiggins
References
- The Royal College of Midwives. 2012. Fyle J (editor). Parental, emotional wellbeing and infant development – An updated good practice guide. London (UK). 36. [Internet]. Available from: https://www.rcm.org.uk/media/4645/parental-emotional-wellbeing-guide.pdf
- Yelland J, McLachlan H, Forster D, Raynor J, Lumley J. How is maternal psychosocial health assessed and promoted in the early postnatal period? Findings from a review of hospital postnatal care in Victoria, Australia. Midwifery. 2007 09; 23, 3: 287-297. [Internet] Available from: https://doi.org/10.1016/j.midw.2006.06.003
- Koh YW, Chan CW, Fong DWT, Lee CP, Leung KY, Tank CSK. Survey on examining prevalence of paternal anxiety and its risk factors in perinatal period in Hong Kong: a longitudinal study. BMC Public Health 15, 1131 (2015). [Internet] Available from: https://doi.org/10.1186/s12889-015-2436-4
- Health Service Executive. National Directors of Public Health Nursing in partnership with Shannon, M. (2014) Quality Integration and Collaboration: A Strategy for Community Nursing. Consultation document. Dublin: Office of the Nursing and Midwifery Services Director. Available from https://healthservice.hse.ie/about-us/onmsd/onmsd/specific-programmes/phn-community-registered-general-nurses.html
- World Health Organisation. Breastfeeding: Recommendations: World Health Organisation; [cited 01/04/2021]. Available from: https://www.who.int/health-topics/breastfeeding#tab=tab_2
- Health Service Executive. Irish Maternity Indicator System: National Report Dublin: Health Service Executive; [updated Nov 2020; cited 01/04/2021]. Available from: https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/national-reports-on-womens-health/imis-national-report-2019.pdf
- Health Service Executive. Guideline on the Observation of a Breastfeed and the Use of the Breastfeeding Observation Assessment Tool (BOAT) Resource: Health Service Executive; [updated 11/07/2018; cited 02/04/2021]. Available from https://www.hse.ie/file-library/guideline-on-the-observation-of-a-breastfeed-and-use-of-the-breastfeeding-observation-assessment-tool-boat-resource.pdf
- University College Cork. Public Health Nursing: About this Course: UCC; [updated 26/03/2021; cited 01/04/2021]. Available from: https://www.ucc.ie/en/ckw01/
- IACST. What is Craniosacral Therapy?: Irish Association of Craniosacral Therapists; [cited 01/04/2021]. Available from: https://iacst.ie/craniosacral-therapy
- Health Service Executive. Mychild.ie: Health Service Executive; [cited 01/04/2021]. Available from: https://www2.hse.ie.