by Dr Louise Santhanam, General Practitioner
When it comes to breastfeeding I wish my GP had known the facts himself before giving out the wrong information
- GPs’ knowledge of breastfeeding management can improve
- Formal medical training on infant feeding is uncommon
- In the absence of formal training GPs rely on personal experience to inform practice
- GPs without training may feel under-confident treating breastfeeding mothers
- Medical training on breastfeeding can improve breastfeeding rates
Infant Feeding Training Needs of GPs
Studies from industrialised countries show that GPs believe that they have a role in breastfeeding promotion 1, 2. However, while GPs express support for breastfeeding they may lack the knowledge to adequately support breastfeeding women. Even in Norway where breastfeeding initiation and continuation are high, GPs scored an average of only 49% correct answers in multiple-choice knowledge questions on the topic2. English GPs and Paediatricians have been found to have incorrect ideas on key public health messages (such as the age for introduction of complementary solid foods) and those who deemed themselves the least competent in breastfeeding support skills were the least likely to seek updates to their training3.
GPs find prescribing for breastfeeding mothers complex, and without awareness of how to access evidence based information they may unnecessarily recommend cessation of breastfeeding or decline to prescribe due to a perceived risk to the infant4.
When surveyed few GPs report having had formal training on breastfeeding (less than 10% in an Irish Study of GPs1 and less than 50% at medical school in an Australian study of GP Registrars5). Studies report a lack of medical role models interested in teaching about breastfeeding and few learning opportunities provided for prospective GPs6. Consistent training and an educational framework for doctors to ensure they are competent in supporting women to establish and maintain breastfeeding has been recommended6. GPs themselves have indicated that breastfeeding should be covered as a topic from medical school level and beyond to address a lack of adequate knowledge2. Observational methods of learning, breastfeeding policies and clinical leadership are among suggestions to improve practice in the UK3.
A recent survey undertaken by the NCT and the WI7 demonstrated the impact of over-stretched midwifery services on postnatal women. Almost 1 in 5 women surveyed felt they were not able to see a Midwife as often as they needed to in the early postnatal weeks and of these 29% then turned to their GP, A&E or walk in centre to get the help they required. When asked what concerns they had wanted to raise, the most common issue postnatally was infant feeding (64%) and the fourth most common problem was sore nipples (27%). Such problems will present to the GP, and improving GP education around infant feeding could assist in the provision of quality care.
Consequences of Inadequate Infant Feeding Training
In health systems, health-care providers influence and support feeding decisions at key moments before and after birth and later, when challenges occur, to maintain exclusive and continued breastfeeding. Nevertheless, substantial gaps in knowledge and skills to support breastfeeding are reported at all levels of healthcare staff.
Rollins N.C et al 2016 Lancet Breastfeeding Series
In the absence of formal training GPs may rely on personal experience to inform practice6. GPs’ confidence in their competency to support breastfeeding mothers was improved if they had personal experience of breastfeeding or their spouse had breastfed. GPs assumed that women with breastfeeding problems would attend a female GP in preference to a male GP, deeming them to be more knowledgable and skilful in breastfeeding management (regardless of whether this was actually the case)8.
Consideration needs to be given to the fact that physician mothers have shown to be a high risk group for breastfeeding discontinuation9 which could influence clinical practice when this is impacted by personal experience. The breastfeeding experience for physician mothers may be negatively affected by expectations of early return from maternity leave, long irregular working hours, and little practical consideration given to their needs at work6.
Research highlights the need for both male and female GPs to be trained in breastfeeding knowledge and practical skills in order to assist breastfeeding women and to work in co-operation with colleagues in the community, rather than simply relying on personal or spousal breastfeeding experience8.
There is a lack of evidence and guidance to assist health professionals in deciding when it is appropriate and necessary to supplement breastfeeding. Additionally, inappropriate recommendations to use breastmilk substitute supplementation can impact on a woman’s confidence. In recent years there has also been a considerable increase in NHS spending on specialised infant milks and many CCGs have implemented prescribing guidance10. Improved GP education on breastfeeding and infant milks could help safeguard the health of both breastfed and formula fed infants and enable appropriate utilisation of NHS funds.
Impact of Improved Medical Training on Breastfeeding Rates
Multiple factors impact on whether a mother initiates and continues to breastfeed including feeding intention prior to the birth, self-efficacy and social support11. Significantly, women are less likely to breastfeed if they perceive that their doctor does not support breastfeeding (either due to no expression of opinion on feeding choice or due to direct encouragement of artificial feeding)6, 12.
Physicians who participated in an education program demonstrated significant improvements in breastfeeding knowledge and long term improvements in the breastfeeding rates of their patients at 4 and 6 months13. GPs who had breastfeeding training reported higher rates of breastfeeding promotion, confidence in the management of breastfeeding problems and had better knowledge scores1. In the UK computer based multi-professional training has been shown to be feasible for updating the breastfeeding expertise of the primary care team, improving practice and generating positive comments about learning in co-operation with primary care colleagues14.
The WBTi Report: Assessment of Health Professional Infant Feeding Training in the UK
The World Breastfeeding Trends Initiative (WBTi) Report for the UK was launched in late 2016 and included an assessment of UK health professional training on infant and young child feeding (IYCF) against the WHO Education Checklist for Lactation. Significantly, it found a number of gaps in current health care professional pre-registration training, including in medical education. Notable learning gaps included the ‘process of milk production and removal’ and ‘guidance for successful breastfeeding’, prescribing for breastfeeding mothers and the responsibility of health workers to practice with respect to The Code. The report includes recommendations to address these issues; including minimum training standards, prescribing education and inclusion of The Code in regulatory bodies’ codes of conduct. Regarding GP training the report recommendations include:
- That the RCGP recommend that breastfeeding specialists have input into GP training, providing content that is in line with Unicef BFI university curriculum guidelines.
- GP trainees observe a session at a specialist-led breastfeeding support service.
World Breastfeeding Trends Initiative (WBTi) A collaborative national assessment of the implementation of key policies and programmes from the WHO’s Global Strategy for Infant and Young Child Feeding. The WBTi brings together the main agencies and organisations involved in aspects of IYCF in a particular country to work together to collect information, identify gaps and generate recommendations for action.
WBTi: UK Report 2016 The first WBTi assessment for the UK. The assessment will be repeated every 3–5 years in order to track trends.
WBTi: Indicators 5 & 6 Supporting Mothers to Breastfeed These indicators form part of the WBTi report. They measure how well healthcare systems support breastfeeding and look in detail at the training of all health professionals who interact with mothers and babies.
WBTi: Education Checklist Infant and Young Child Feeding Topics Documents key objectives for health professional education to ensure good infant feeding support for infants, young children and mothers.
WBTi: Indicator 5- Health and Nutrition Care Systems (in support of breastfeeding & IYCF) An assessment tool to determine if pre-service education curriculum and skills training 1) supports optimal infant and young child feeding 2) mothers and children and 3) promotes health care worker responsibility to The International Code of Marketing of Breastmilk Substitutes (‘The Code’).
Unicef UK Baby Friendly Learning Outcomes
Unicef UK Baby Friendly Initiative: Learning Outcomes for Medical Students Published in 2019, these learning outcomes for medical students are intended to set a standard for the level of knowledge and understanding of infant feeding that could be reasonably expected of a newly qualified doctor. Supporting materials such as slide sets, guidance for lecturers and e-learning are planned. It is hoped that the learning outcomes will provide a stimulus to universities to start to consider what should be covered in relevant curricula and then to take action to make that a reality.
Where educational resources and events are developed or sponsored by industry, the clinician should be mindful of the possibility of bias. GPIFN aims to signpost to independent information and educational resources wherever possible.
Academy of Breastfeeding Medicine A worldwide organisation of Physicians dedicated to the promotion, protection and support of breastfeeding and human lactation. The Academy of Breastfeeding Medicine produces evidence-based protocols on the medical management of breastfeeding issues.
A Breastfeeding Paediatrician by Victoria Thomas Medical Woman (Autumn 2014) Article highlighting the important issues for physician mothers supporting breastfeeding women.
- Finneran B, Murphy K. Breast is best for GPs–or is it? Breastfeeding attitudes and practice of general practitioners in the Mid-West of Ireland. Irish Medical Journal. 2004;97(9):268-70.
- Svendby H, Løland B, Omtvedt M, Holmsen S, Lagerløv P. Norwegian general practitioners’ knowledge and beliefs about breastfeeding, and their self-rated ability as breastfeeding counsellor. Scandinavian Journal of Primary Health Care. 2016;34(2):122–129.
- Wallave L, Kosmala-Anderson J. A training needs survey of doctors’ breastfeeding support skills in England. Maternal & Child Nutrition 2006;2(4):217-31.
- Jayawickrama H, Amir L, Pirotta M. GPs’ decision-making when prescribing medicines for breastfeeding women: Content analysis of a survey. BMC Research Notes. 2010;3(1):82.
- Brodribb W, Fallon AB, Jackson C, Hegney D. Breastfeeding knowledge – the experiences of Australian general practice registrars. Australian Family Physician. 2009;38(1-2):26-9.
- Brodribb W Breastfeeding — a framework for educating the primary care medical workforce 2012;20(2):25-30.
- The WI and NCT: Support Overdue- Women’s Experiences of Maternity Services 2017
- Brodribb WE, Jackson C, Fallon AB, Hegney D. Gender and personal breastfeeding experience of rural GP registrars in Australia – a qualitative study of their effect on breastfeeding attitudes and knowledge. Rural Remote Health. 2007;7(3):737.
- Sattari M, Levine D, Serwint J. Physician Mothers: An Unlikely High Risk Group—Call for Action. Breastfeeding Medicine. 2010;5(1):35-39.
- First Steps Nutrition Trust: Specialised Infant Milks in the UK 0-6 months- Information for Health Professionals September 2019, scroll down to the purple report.
- Meedya S, Fahy K, Kable A. Factors that positively influence breastfeeding duration to 6 months: A literature review. Women and Birth. 2010;23(4):135-145.
- Odom E, Li R, Scanlon K, Perrine C, Grummer-Strawn L. Association of Family and Health Care Provider Opinion on Infant Feeding with Mother’s Breastfeeding Decision. Journal of the Academy of Nutrition and Dietetics. 2014;114(8):1203-1207.
- Holmes A, McLeod A, Thesing C, Kramer S, Howard C. Physician Breastfeeding Education Leads to Practice Changes and Improved Clinical Outcomes. Breastfeeding Medicine. 2012;7(6):403-408.
- Ingram J. Multiprofessional training for breastfeeding management in primary care in the UK. International Breastfeeding Journal. 2006;1(1):9.