Improved breastfeeding rates through evidence-based guideline changes
Submitting InstitutionSwansea University
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Nursing, Public Health and Health Services
Summary of the impact
The societal, economic and health benefits of breastfeeding include
reduced infections in infants, cancers in mothers, cardiovascular
disorders in both, and costs to the NHS (UNICEF UK 2012). Breastfeeding
initiation rates in England improved from 66.2% in 2005/6 to 73.7% in
2010/11. Swansea work improved services, health and welfare because we:
- identified for the first time the need to restrict doses of
epidural opioid analgesia during labour (R1)
helped midwives identify mothers in greatest need of
breastfeeding support (R2)
- developed public and professional awareness of the impact of drugs in
labour on breastfeeding.
We recommended that doses of analgesia be minimised and mothers receiving
multiple medicines in labour targeted for additional breastfeeding support
(R1-3). These recommendations reached most midwives and students in the
English-speaking world through NICE (National Institute for Health
and Care Excellence), Intrapartum Care Guideline 2007 (C1 p.123)
and our textbooks (R4, 5). NICE guidelines form the basis of hospital
policies and procedures in the UK and beyond. Doses were lowered (details
below) and breastfeeding rates improved.
The benefits of breastfeeding to infants and mothers underlie World
Health Organisation and UK government policies on infant nutrition. Our
group explored the impact of drugs in labour on infant feeding. Literature
searches for the standard midwifery textbook (R4) suggested that it is
biologically plausible that analgesics and uterotonics routinely
administered in labour adversely affect the complex, and incompletely
understood, physiology of breastfeeding. These hypotheses were supported
in a series of cohort studies undertaken in Swansea.
- A cohort of first time mothers delivering in Singleton hospital 2000,
data extracted from patient records (n=425) (R1)
- Analysis of the Cardiff Births Survey 1989-1999 (n=48,366) (R2)
- An internet survey (n=284) (R3)
We were the first to report:
- A dose-response relationship between epidural fentanyl and reduced
breastfeeding rates by up to 40% (R1)
- A reduction of 6-8% in breastfeeding rates in women receiving
intramuscular oxytocin or Syntometrinef8e8 for routine prophylaxis of post
partum haemorrhage (R2).
- Birth complications, accompanied by medications, are associated with
breastfeeding discontinuation for physical (pain and difficulties), but
not psychosocial (lifestyle, support, body image and embarrassment)
This work questions practices which have remained unchallenged and unchanged
since the widespread introduction of epidural fentanyl and routine
administration of uterotonics in the third stage of labour in the 1980s.
Identification of previously unsuspected adverse drug reactions is an
important strategy for harm avoidance.
Infant feeding data have been collected in <3% of trials of pain
relief in labour (Cochrane 2012, Issue 3. Art. No.: CD009234), and <20%
of trials covering the third stage of labour (Cochrane 2011 Issue 11. Art.
No.: CD007412), increasing the significance of our observation studies. A
dose- response relationship is an important quality indicator (J Clin
Epidemiol. 2011 64; 1311-6). Accordingly, our work has been disseminated
widely, and informed the Cochrane overview (Cochrane 2012, Issue 3. Art.
No.: CD009234), and recommendation that breastfeeding be included as an
outcome for all future trials in the Cochrane Pregnancy and Childbirth
Ours is the only cohort with fentanyl doses, although others have linked
epidurals to reduced breastfeeding. A SCOPUS search (20.6.2012) of the key
terms "feeding" "dose" "epidural" found no earlier data exploring the
dose/response relationship between opioid analgesia and infant feeding.
Oxytocin for labour augmentation has been implicated in smaller studies,
but we are the only group using a large naturalistic cohort to report the
impact of routinely administered oxytocin on breastfeeding. Ergometrine
alone reduces breastfeeding, but we are the only group reporting an
association in combination with oxytocin.
Key researchers: Sue Jordan, Swansea university 1992-present,
Alan Watkins, Swansea university 1986-present, associate professor
Gareth Morgan, Swansea university 2002-present, professor of
Simon Emery, ABMU HB, 1989-present, consultant obstetrician
Amy Brown, Swansea University, 2005-present, senior
lecturer. All work in Swansea.
References to the research
R1. Jordan S., Emery S., Bradshaw C., Watkins A., Friswell W. 2005
The Impact of Intrapartum Analgesia on Infant Feeding. BJOG: 112,
927-34. (By 31.7.13, 40 citations, Impact factor (IF) 3.76, 3rd
in field for article influence score (Thompson ISI 2012).
R2. Jordan S, Emery S, Watkins A, Evans J, Storey M, Morgan G.
2009 Associations of drugs routinely given in labour with breastfeeding at
48 hours: analysis of the Cardiff Births Survey. BJOG; 116(12) 1622-30
(see REF outputs) (13 citations)
R3. Brown AE., Jordan S. 2013 Impact of Birth Complications on
Breastfeeding duration: an internet survey. J. Ad. Nursing.
69(4):828-39 DOI: 10.1111/j.1365-2648.2012.06067.x IF 1.53
R4. Jordan S. 2002, 2010 `Pharmacology for midwives: the
Evidence Base for Safe Practice' Palgrave/ Macmillan, Basingstoke 1st
& 2nd edition ISBN-13: 978-0-230-21558-0 pp. 486
R5. Jordan S. 2011 Pharmacology and the midwife In: MacDonald S.,
Magill-Cuerden J. (eds) 2011 Mayes' Midwifery: A text book for
Midwives pp.123-136. 14th edition Elsevier, Edinburgh.
R6. Jordan S. 2006 Infant feeding and analgesia in labour Int.
Breastfeeding J.: 1: 25 doi: 10.1186/1746-4358-1-25 (11 citations).
Grants supporting this work:
G1. Jordan et al. 2005 was supported by Welsh Office of
Research and Development: Emery and Jordan, 2002-3, An exploration of
the drugs administered during normal labour on infant feeding,
G2. PhD studentship, Brown: Maternal control of milk feeding.
ESRC 2005-2009, £45,000.
G3. National Institute Social Care and Health Research Wales,
Research Development Group for Pregnancy, childbirth, infant feeding and
medicines, £9,000, PI Jordan.
Details of the impact
Low breastfeeding rates are an intransigent public health problem with
multiple causes (R6). Our work identifying links between medicines in
labour and reduced chances of breastfeeding has focused on one aspect of
this complex aetiology - iatrogenic harm.
Public and professional awareness was raised by: 1) The media,
including front page of The Times 1.9.2009: and "Concern over
painkillers led the NHS to revise its guidelines on epidurals", BBC, Daily
Mail, Western Mail, Reuters, UNICEF baby friendly website, BMJ, NCT
journal; 2) 7 clinical guidelines and 7 books for clinicians; 3) 56
citations by 31.7.13 in midwifery, obstetrics, paediatrics, anaesthetics,
public health, chiropractice, pharmacy publications. The standard
textbooks (R4,5) ensure that our research recommendations reach most
midwifery students working in English, Farsi and Indonesian: 40 of 65 UK
midwifery courses have adopted our textbook (R4). The >5,800 and
>3,800 copies of the English 1st & 2nd
editions sold reach most of the UK's 35,000 midwives and many in
Australasia, USA, Ireland and Malta (July 2013). Accordingly, when labour
has been extensively medicated, practitioners are now aware of the need
for additional support and time to allow the body to eliminate medicines.
The impact on education is evidenced by suggestions that the book makes
"care safer for mothers and babies" (C9). Citing our work in R1, West
& Marasco (2009 p.59 C2) advise: "epidurals (...) can temporarily
diminish infants' nursing behaviours (...); it may take a little more
work to get breastfeeding started". The position is summarised by
the National Childbirth Trust (NCT): "NCT has been concerned
about use of opioids during labour and their impact on women's
experiences of establishing breastfeeding, breastfeeding initiation and
continuation for many years. We consider the work in Swansea, which
centred on the impact of drugs in labour on breastfeeding, to be really
important. The recommendation to minimise doses of epidural fentanyl was
adopted by NICE in the Intrapartum Care guidelines, and the literature
indicates that doses are now lower. Breastfeeding rates have improved,
for a number of reasons. Lower doses of opioids may be contributing to
women having more positive experiences of feeding in the very earliest
days, and to this improvement in rates. The associations between
medicines and breastfeeding rates, together with knowledge of the
importance of breastfeeding, persuaded the Cochrane group to include
infant feeding as one of the core outcomes for future trials in
childbirth. NICE recommendations were based on Swansea work." (C8)
Incorporation into Guidelines Citing our work on the association
between the dose of fentanyl and breastfeeding, 7 guidelines (C1-7)
recommend restrictions on epidural fentanyl doses. Our recommendations
(R1) against high doses and the need for further research were adopted by
NICE: the NICE Evidence statement reports the association between the dose
of fentanyl and the success of breastfeeding, and indicates "a need for
studies (...): to assess the impact of low-dose epidurals with opioids
(fentanyl) on neonatal outcomes, including resuscitation and
breastfeeding." (NCC 2007 p.123 C1). Recommendations (p.14 C1)
include informing women that "opioids may interfere with breastfeeding".
The US Academy of Breastfeeding Medicine Protocol (2008 p.129 C2), citing
our work (R1), states: "consideration should be given to the type and
dose of analgesia. Higher doses of intrapartum fentanyl may impede
establishment of breastfeeding." Also citing R1 and a small trial,
Reynolds recommends: "When prolonged epidural analgesia using local
anaesthetic-opioid combination is extended for emergency section, it is
unwise, for the baby's sake, to give further opioid epidurally or
systemically until after delivery" (Best Pract Res Clin Obstet
Gynaecol. 2010;24(3):289-302 p.298). Also, if epidurals are
contraindicated, the more rapidly metabolised remifentanil is now
selected, as it is less likely to enter the foetus and depress neonates'
Practice changes NICE now recommends initiation of epidural
analgesia with bolus doses of 10- 30mcg fentanyl (C1 p.137). Previously,
analgesia was initiated with bolus doses of 100mcg (Anesth Analg. 2000;
91(2):374-8): in 2003 a bolus of 50mcg was considered `ultra low dose' (J
Obstet Gynecol Neonatal Nurs.;32(3):322-31). In local hospitals, epidural
fentanyl total doses now range 40-240 mcgs. In the COMET trial, in 2000,
155/757, 20.5% parturients received >200mcgs epidural fentanyl and
41/757, 5.4% received >300mcgs (Anaesthesia. 2010; 65(2):145-53).
Changes in Breastfeeding Rates Publication of our work (R1 in
2005) and guidelines citing it (2007) were followed by improved
breastfeeding initiation in England between 2005 & 2010 (Figures from
Dept. of Health Statistics).
||% (95% CI)
||OR increase each
year from 2005
||% (95% CI)
The deceleration in improvement from >1% to <0.5% pa after 2010
intimates that the impetus for improvement was discrete and
sustainable. Similarly, 6-8 week data (only available from 2008/9) indicate
improvement to 2009/10, but not thereafter. The quinquennial Infant Feeding
Surveys from 1980 indicate that breastfeeding rates deteriorated when
epidural fentanyl and routine uterotonics were introduced in the 1980s, and
recovery was co-temporaneous with our work.
Alternative explanations, and commonly held beliefs regarding strategies
to improve breastfeeding rates, are not supported by evidence from
industrialised countries. 1) Well-conducted trials suggest that
psychosocial interventions and support do not improve rates (BMJ.
2009;338; 392-5 & 338; 388-92). 2) Systematic reviews indicate that
lay support confers no advantages in the UK (BMJ 2012; 344:d8287), and
benefits of any support are minimal or non-significant in countries with
low or intermediate initiation rates, particularly when only studies with
low risk of bias are considered (Cochrane 2007 Jan 24(1):CD001141; 2012
May 16(5) CD001141). 3) Lay support is difficult to obtain, due to limited
supply of altruistic mothers and inadequate administrative support (Soc
Sci Med. 70(5):769-778). 4) Delivery in `baby friendly' hospitals does not
improve breastfeeding rates at 1 month (Int J Epidemiol.;35(5):1178-86).
Without evidence for the efficacy or effectiveness of other feasible
strategies to improve breastfeeding, awareness of the impact of drugs in
labour (via NICE and other guidelines, textbooks, press coverage,
UNICEF and NCT), and subsequent decreases in fentanyl doses, are
Health gains Before 2005, high fentanyl doses affected at least
3-4% of the 750,000 infants born each year in the UK: in our hospital, 4%
primiparae received over the current maximum dose of epidural fentanyl.
Practice and dose changes related to our work were important in the 7.5%
increase in breastfeeding initiation 2005-2010 and the subsequent
reduction in admissions for diarrhoea and gastroenteritis (A09) (Hospital
episode statistics 2012). A 2-4% increase in breastfeeding rates improves
health by reducing UK infant hospital admissions for diarrhoea and
lower respiratory tract infections by 2% and 1%. An extra 2-4% UK women
breastfeeding for 3 months decreases childhood obesity by 1% (R2);
underlying mechanisms (Brown et al., Paediatric Obesity 7; 382-90)
and preventive strategies (Brown et al. 2011, JAN 67; 1993-2003)
are incorporated in several guidelines (NCT, UNICEF, US Surgeon General).
Breastfeeding also has measurable impact on: necrotising enterocolitis,
sudden infant death, asthma, leukaemia and cardiovascular disease in
infants, breast & ovarian cancer in mothers, and diabetes in infants
& mothers (UNICEF UK, 2012).
Cost savings Improved infant and maternal health translate into
cost savings. Increase in any breastfeeding at 6 months by 2-4% saves
>£1m pa from reduced gastrointestinal, respiratory and ear infections.
Reducing the number of women who never breastfeed by 2-4% saves >£3m in
breast cancer expenditure over the lifetime of the cohort, exclusive of
quality adjusted life years. Where 1% of those who "never breastfeed"
initiate breastfeeding, the associated small increase in infants' average
IQ results in a gain of over £278 million in economic productivity over
the lifetime of each annual birth cohort (UNICEF UK, 2012).
In summary, identification of the association between medicines
administered in labour and breastfeeding raised public and
professional awareness of a health risk and engendered practice changes,
including lower doses of opioid analgesics. Subsequently,
breastfeeding initiation rates increased 2005-2010 (66.2-73.7%). This
represents a significant avoidance of harm.
Sources to corroborate the impact
The work is cited in 7 clinical practice guidelines:
C1. NCC/ National Collaborating Centre for Women's and Children's
Health, commissioned by NICE (2007) Intrapartum care; care of healthy
women and their babies during childbirth: clinical guideline.
London: RCOG Press 2007. P. 122-3, section 6.5, ref. 187 http://www.gserve.nice.org.uk/nicemedia/pdf/IntrapartumCareSeptember2007mainguideline.pdf
C2. Academy of Breastfeeding Medicine (ABM) clinical protocol 5.
Breastfeeding Medicine: official journal of the ABM; 2008 Jun;3(2):129-32
Also: National Guideline Clearginghouse 2009 Peripartum breastfeeding
management for the healthy mother and infant at term. US. Dept Health
& Human Services http://www.guideline.gov/content.aspx?id=13406
C3. New Zealand College of Midwives (Inc.) 2011 NZCOM Consensus
Statement: Prescribing and administration of Narcotic Analgesia in Labour
[Auckland?], New Zealand, http://www.midwife.org.nz/quality-practice/consensus-statements-and-guidelines
C4. West D, Marasco L 2009 The breastfeeding mother's guide to
making more milk New York, McGraw-Hill@9780071598583 0071598588
C5. Hey E. (2007) Neonatal formulary and Drug Use in the First
Year of Life. 5th edition. Wiley Blackwell / BMJ Books, Oxford.
C6. Royal College of Midwives 2012 Evidence-based Guidelines for
Midwifery-led Care in Labour: Early Breastfeeding http://www.rcm.org.uk/college/policy-practice/evidence-based-guidelines/
C7. Ministerio De Sanidad Y Política Social. Guía de Práctica
Clínica sobre la Atención al Parto Normal (clinical practice guidelines on
normal childbirth care). Servicio Central de Publicaciones del Gobierno
Vasco; 2010. ref 356 p.235-7 Available: http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/pdf/equidad/guiaPracClinPartoCompleta.pdf.
C8. Head of Research and Information, NCT, Acton, London, e mail
27.3.13 - 15.32
C9. Senior Lecturer, School of Nursing and Midwifery, De Montfort
University, UK, e mail 30.7.13
C10. 26 news reports: The Times 1.9.2009. Media citations include:
BBC, Daily Mail, Western Mail, Reuters, BMJ, NCT journal: Dodds R.
2010, UNICEF baby friendly website, http://www.unicef.org.uk/BabyFriendly/Search/?SearchText=Jordan
News Digest. 49(1) 20 accessed 1.8.13. Invitations: HTA
panels; NICE stakeholders for intrapartum care guidelines; Cochrane
Groups; Keynote addresses: 2010 Patient safety conference. Groote Schuur
Hospital, Cape Town; RCN Congress seminar 2008; editorial boards:
International Breastfeeding Journal, International Nursing Review, Journal
of Nursing Management, Open Nursing Journal.