There is so much to be grateful for when we're being cared for by a health care system in an advanced economy

Excellence in affordable and accessible health care, including for mothers and babies, is a fundamental human right, not yet afforded to many in low and middle income countries - and also not yet afforded to some groups within advanced economies.

Before all else, I acknowledge how fortunate people like me are to be living in advanced economies and receiving the protection of world-class health systems and hospitals.

I also acknowledge that everyone helping you in the hospital setting wants the best possible outcomes for you and your baby. Hitches and glitches in breastfeeding support is a systems problem, not the fault of any particular practitioner!

It's common to strike hitches and glitches in breastfeeding support when you're in hospital

But here is a list of things which commonly go wrong for us as women in hospital settings, even in high income countries, when we're trying to breastfeed our newborn. Unfortunately, these problems often occur even when that hospital has Baby Friendly Accreditation.

• Lots of conflicting advice is given to patients by staff about breastfeeding and lactation, infant crying, and infant sleep.

• A poor understanding of the biomechanics of breastfeeding results in a cascade of problems from the first hours and days after the birth. You can see a video of how babies breastfeed here.

• It can be difficult to get your body comfortable for breastfeeding, because of the furnishing choices made by hospitals. You can find out about physical comfort and breastfeeding here.

  • The chairs in the postpartum wards often have high arms which interfere with fit and hold (and may be too small for generously-bodied women).

  • Some chairs recline but lift the woman's feet from the floor, which means that she can't use her feet on a footstool (through which she has good contact with the floor) to stabilise her spine.

  • The pillows available are too soft for elbow support. There aren't enough towels in the room to layer up for elbow support.

• The clamp on the umbilical cord causes discomfort to newborns, and makes micromovements difficult. You can find out about the importance of micromovements here and here.

• Too much emphasis on skin-to-skin contact can mean that micromovements are difficult in breastfeeding because the mother and baby's skins might stick together and baby can't slide easily. A light cotton singlet or jumpsuit may work best for some mother-baby pairs. You can find out about micromovements here.

• The need for regular monitoring and one-size-fits-all policies in the hospital setting can result in premature use of either antenatal colostrum or formula, in a way that undermines stimulation of your breasts in the first days of breastfeeding.

  • You can find out about antenatal colostrum use here.

  • You can find out about protecting newborn safety and formula use here.

• Some staff, trying to help, still use their own hands to squeeze or shape the mother's breast and push baby on. Shaping of the breast and using cross-cradle hold has been shown in one large, well-conducted study to increase the rates of nipple pain fourfold, and any forcing of baby onto the breast can result in a conditioned dialling up. You can find out about conditioned dialling up here.

• Staff generally aim to support mothers to initiate breastfeeding as soon as possible after the birth. This positive intention can also accidentally ramp up anxiety if baby is not immediately taking to the breast. If your baby is accidentally put under pressure, a conditioned dialling might result. You can find out about conditioned dialling up here.

• Nipple shields are overused, due to our health systems' fit and hold blind spot. Yet some women with nipple pain may benefit from the use of the nipple shields even prior to the milk coming in. By the time many women have transitional milk, they already have cracks or ulcers on their nipples, making it very difficult to breastfeed. You can find out about nipple shield use here.

• There is a tendency to recommend spaced feeds (every two or three hours) in hospital settings, which is different to frequent and flexible breastfeeding. You can find out about frequent and flexible breastfeeds here.

• Parents are advised to look out for feeding cues, but this can be quite unhelpful. You can find out why here.

About the photos on this page

If the mother in the photo at the top of this page is experiencing any pain with her newborn's breastfeed, help with fit and hold is required, even though she is still in the first hours post-birth. This woman may be experiencing nipple and breast tissue drag because

• Her baby's upper lip is visible - the little nose is well away from the mother's breast skin.

• Her baby's head is in the crook of the woman's arm, which limits her capacity to experiment with micromovements.

If there are no problems, then there is no reason to intervene.

The kind staff member in the second photo at the bottom of this page has her hand on the back of the newborn's head, which turns off breastfeeding reflexes. She is beginning to shape the woman's breast. Unfortunately this well-meaning approach can result in either nipple pain for the mother or conditioned dialling up for the baby.

Selected references

Joy F, Morison A, Soltani H. Stakeholders’ views of the Baby Friendly Initiative implementation and impact: a mixed methods study. International Breastfeeding Journal. 2024;19(49):https://doi.org/10.1186/s13006-13024-00639-13008.

Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth. 2016;29:336-344.