Some of the long awaited work about expressing in pregnancy for women with diabetes, from Forster et al, and the DAME study has been published. The implications of this work are important for women with diabetes who plan to breastfeed, and hopefully the findings will lay to rest concerns about expressing in pregnancy and risk of preterm labour. The DAME study found no evidence of harm from advising low-risk, pregnant women with diabetes to hand-express breast milk from thirty-six weeks gestation.
There was misreporting of this study in the media with headlines missing out the ‘diabetes’ context, and others using photographs of breast pumps embedded within the stories. To be clear, the study was about hand expressing from thirty-six weeks gestation for low-risk pregnant women with diabetes. What now requires further research is whether other women at risk of low lactation would benefit from hand expressing and colostrum harvesting in pregnancy.
When considering women who may be at risk of low lactation a discussion about lactation ‘insufficiency’, and what is often described as biological or ‘real’, and what is described as ‘perceived’ is needed. Alison Stuebe discusses issues of ‘perceived’ and ‘real’, and suggests that from a health and wellbeing perspective it may not really matter whether biological and perceived are counted together as, “… mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support.”
It is unknown exactly how many women are at risk of primary lactation insufficiency although we know that diabetes and other medical conditions are associated with delayed lactogenesis, and some women may have supply challenges due to issues with low glandular tissue amounts, or previous breast surgery. Two percent is often quoted for numbers of women who may have lactation insufficiency, and Neifert suggested in 2001 that up to 5% of women may have primary lactation issues because of breast anatomy or medical conditions. New Zealand Ministry of Health figures from 2014 suggest that out of 61,000 births, 6.6% of these pregnancies were affected by diabetes.
A full breast milk supply requires sufficient breast glandular tissue, intact nerve pathways and ducts, hormone production, and frequent and effective milk removal. If any of these are parts are compromised there is a risk that full lactation may not be reached. Lactation issues with a secondary cause are as difficult to calculate as primary. Secondary refers to women who have a full lactation, or the capacity to develop a full lactation, but some ‘interference’ occurs, which results in low lactation issues. Birth interventions, caesarean births, sleepy babies, latching problems, and lack of support can all lead to secondary issues with milk supply.
Because environmental and social factors also play a significant role in lactation, how we approach discussions about lactation and breastfeeding during pregnancy is also significant, as is what happens to women in labour, birth and the post-birth period. Amy Brown explored the psychosocial and cultural issues around breastfeeding and their impact on the physiology of breastfeeding, why many mothers stop breastfeeding before they planned to, and why low milk supply is commonly cited as the reason. Brown highlights how psychological, social and cultural influences can strongly influence the physiology of breast milk supply. Otsuka et al, in a study of 262 breastfeeding women in Japan found that 73% of the women had a perception of insufficient milk supply, and the Growing up in New Zealand study found that 45% of the women in their cohort cited insufficient milk supply, with 32% also citing their babies were not satisfied with breastfeeds.
In New Zealand there are stories of women with low risk pregnancies, without obvious risk for low milk supply, who have been advised to express colostrum in pregnancy. What is unknown is the outcome of these interventions. Whether milk supply was enhanced, maternal confidence increased or subdued, breastfeeding outcomes were favourable or unfavourable.
Rachel O’Brien, whose Master’s thesis was about women in the US and low milk supply, wrote an interesting blog on milk supply and psychology, where she used response expectant theory (RET) to explain why hearing “over and over” about low milk supply could cause bodies to “respond in the way that we expect them to – by making less milk than we need.” Kirsch describes RET as the anticipation of automatic, subjective, and behavioral responses to particular situational cues, suggesting a non-volitional response can occur due to expectations of one’s own response to a situation. When discussing Kirsch’s RET theories, Stewart-Williams, suggests that the hypothesis has “an intuitive plausibility. For instance, the expectation of anxiety is likely to be anxiety provoking, and the expectation of depression is likely to be depressing.”
Amy Brown discusses breastfeeding outcomes, why engagement in pregnancy is important for breastfeeding, and how women who feel prepared, knowledgeable, and confident about breastfeeding have better outcomes after birth. Brown examined behavioural factors contributing to ‘successful’ breastfeeding and found that women with high levels of confidence, and determination about their breastfeeding decisions, managed to navigate their way through the challenges they faced to meet their goals for breastfeeding. This appears to illustrate the positive significance of the development of confidence and self-efficacy.
Funding and resources to undertake breastfeeding research, so practice can be underpinned with evidence wherever possible, is not readily available. Another issue for breastfeeding is the lack of support for breastfeeding women, and this includes limited or no maternity protection, insufficient paid maternity leave, and a lack of government engagement and recognition of breastfeeding and its link to public health. Peer support is recommended by the World Health Organisation for initiation and continuation of breastfeeding. Recent research by Aimee Grant et al, from Cardiff University, found that services for breastfeeding peer support were inadequate. A similar situation exists in New Zealand where there are patchy peer support services available.
There are many interlocking pieces in the puzzle of low lactation including clinical, iatrogenic, psychological, and the care women receive, and until we have more evidence and information to complete the picture, a tailored approach is necessary. This means grounded in up to date practice and care that boosts maternal confidence and promotes self-efficacy, where the individual woman’s situation is the primary concern, and if there are previous experiences of breastfeeding, these are taken into account.
Dahlen discusses “modern maternity care” and whether it has “morphed into a super trawler of risk, scooping up with its well-meaning ‘net’ the bycatch” – well and healthy women.  Promoting ante-natal colostrum harvesting to all pregnant women inevitably pulls low risk women into the ‘net’, and may contribute to increased levels of anxiety about milk supply. Some women with risk factors for low lactation are likely to benefit from harvesting colostrum in late pregnancy, and they also need ongoing support for the initiation and establishment of breastfeeding. Women without risk factors for low lactation need support for the development of their breastfeeding self-efficacy and confidence. Lauwers and Swisher discuss the medicalisation of breastfeeding and suggest that:
“It is incumbent on all who work directly with families to be a part of a solution in protecting breastfeeding, not part of the problem”
 Forster, D. A., Moorhead, A. M., Jacobs, S. E., Davis, P. G., Walker, S. P., McEgan, K. M., Opie, G, F., Donath, S. M., Gold, L., McNamara, C., Aylward, A., East, C., Ford, R., & Amir, L. H. (2017). Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]: a multicentre, unblended, randomised controlled trial. The Lancet, 389:2204-2213.
 Stuebe, A. (2012). How often does breastfeeding just not work? Breastfeeding Medicine/Physicians blogging about breastfeeding. https://bfmed.wordpress.com/2012/10/15/how-often-does-breastfeeding-just-not-work/
 Niefert, M. R. (2001). Prevention of breastfeeding tragedies. Pediatric Clinics North America, 48(2):273-297.
 Ministry of Health. (2014). Diabetes in Pregnancy. Wellington, MOH.
 Brown, A. (2015). Milk supply and breastfeeding decisions: the effects of new mothers’ experiences. NCT Perspective, Issue 29, December.
 Otsuka, K., Dennis, C.-L., Tatsuoka, H., & Jimba, M. (2008). The relationship between breastfeeding self-efficacy and perceived insufficient milk among Japanese mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37:546–555.
 Morton, S. M. B., Atatoa Carr, P. E., Grant, C.C., et al. (2012). Growing Up in New Zealand: A longitudinal study of New Zealand children and their families. Report 2: Now we are born. Auckland: Growing Up in New Zealand
 O’Brien, R. (2016). You get what you expect: low milk supply and psychology. https://rachelobrienibclc.com/blog/you-get-what-you-expect-low-milk-supply-and-psychology/
 Kirsch, I. (1997) Response expectancy theory and application: A decennial review. Applied and Preventive Psychology, 6(2):69-79.
 Stewart-Williams, S. (2004). The placebo puzzle: Putting together the pieces. Health Psychology, 23(2):198-206.
 Brown, A. (2016).What Do Women Really Want? Lessons for Breastfeeding Promotion and Education. Breastfeeding Medicine, 11(3):102-110.
 Grant, A., McEwan, K., Tedstone, S et al. (2017). Availability of breastfeeding peer support in the United Kingdom: A cross sectional study. Maternal and Child Nutrition, 13(3):e12476. https://doi.org/10.1111/mcn.12476
 Dahlen, H. (2014).Managing Risk or Facilitating Safety? International Journal of Childbirth, 4(2):66-68.
 Lauwers J., Swisher, A. (2011). Counseling the Nursing Mother: A Lactation Consultant’s Guide, 5th edition, p. 248. Sudbury, Jones and Bartlett.