The World Health Organization recommends that infants are exclusively breastfed until six months of age, and to continue breastfeeding after with complementary food.1 The benefits of breastfeeding for both mother and infant are well studied. For the child the benefits include but are not limited to decreased childhood ear and gastrointestinal infections, asthma, decreased rates of childhood obesity and diabetes.2–4 For the mother, benefits include decreased rates of hyperlipidemia, diabetes, cardiovascular disease, ovarian and breast cancer, decreased risk of postpartum depression, and increased postpartum weight loss. Also, for both mother and baby, breastfeeding increases bonding between mother and infant. 2–4
Due to these maternal infant and benefits, worldwide orchestrated efforts have been made to increase awareness and to promote breastfeeding, such as the Baby Friendly Hospital Initiative by WHO and UNICEF, to help motivate facilities providing maternity and infant care by implementing the Ten Steps to Successful Breastfeeding, a summary of policies and procedures developed to support breastfeeding.5 A systematic review of 58 studies on maternity and newborn care published in 2016 demonstrated clearly that adherence to the Ten Steps impacts early initiation of breastfeeding immediately after birth, exclusive breastfeeding, and total duration of breastfeeding.6
Significant improvements in breastfeeding rates have been made in the past decade, and the push remains to increase exclusive breastfeeding rates. The WHO Global Targets 2025 include a target increase in the rate of exclusive breastfeeding in the first six months up to at least 50%.7 The CDC healthy people 2020 objectives aimed to increase the proportion of infants ever breastfed to 81.9% and infants breastfed exclusive through six months to 25%.6
Despite an overall increase in breastfeeding initiation and exclusive breastfeeding rates in the nation, rates are variable between states, regions, and hospitals. Studies have also shown that women with lower levels of education, who are non-white, non-Hispanic, or of lower socioeconomic status face significant barriers and are less likely to meet their breastfeeding goals.8,9
Prenatal breastfeeding education helps improve breastfeeding rates and is a recommended strategy from the United States Preventive Services Task Force and the WHO/UNICEF.10 Most women make their breastfeeding decisions before conception and/or early in the pregnancy, which makes prenatal breastfeeding education and counseling vital. One study showed that breastfeeding education was only addressed at 29% of visits and for less than 40 seconds, which shows that breastfeeding may be inadequately addressed, especially during busy clinic visits.11,12 Healthcare worker-led intervention or an intensified healthcare provider training program for breastfeeding has been shown to significantly increase exclusive breastfeeding rates for six months and affect maternal knowledge about breastfeeding.13,14 Furthermore, in another study including low-income mothers who had Medicaid insurance or was uninsured, most participants agreed that educational breastfeeding interventions, such as on-demand videos, showing breastfeeding latch, positioning, benefits, neonatal behavior, and legal issues related to breastfeeding and work would have helped them exclusively breastfeed.15 Prenatal confidence in breastfeeding is one of the most significant predictors of breastfeeding duration. As such, women with low confidence in breastfeeding often feel that they have insufficient milk supply, start formula supplementation, and eventually stop breastfeeding.16 Prenatal classes, which addressed breastfeeding myths and concerns, may increase feelings of breastfeeding self-efficacy and showed greater rates of breastfeeding initiation and duration among low SES black women.16 Based on this evidence, ensuring that all pregnant mothers receive breastfeeding education can reasonably increase rates of breastfeeding.
Hand expression is an effective technique for obtaining colostrum and it has been shown that in the postpartum period, mothers who hand expressed in the immediate postpartum period were more likely to be breastfeeding at two months (96.1%) compared to mothers who used an electric pump (72%).17,18 A recent 2018 cross sectional study of 688 women showed that 80.9% of surveyed women would consider antenatal breast expression if it was found to be helpful to prepare for breastfeeding.19 Several qualitative studies showed that confidence in breastfeeding increased with experiences of antenatal milk expression and that antenatal milk expression allowed women to store colostrum during pregnancy.20,21 A prospective study of 180 patients found that those who expressed breast milk daily after 37 weeks gestation found it easier to initiate breastfeeding and was found to have sufficient milk flowing within half an hour of initiation of breastfeeding (94.4%) compared to patients in control group (70%).22
However, the safety of antenatal hand expression has been highly debated as oxytocin release from antenatal nipple stimulation has been thought to cause adverse maternal and infant effects. Interestingly, a randomized controlled trial that examined antenatal hand expression starting at 36 weeks’ gestation in women with diabetes in pregnancy demonstrated no maternal differences in labor onset, type of delivery, blood loss, or maternal hypoglycemia.23 Similarly, antenatal expression was not associated with worse infant outcomes, including admissions to the neonatal ICU, shorter mean gestation ages, lower birth weight, or lower Apgar scores.23 In fact, evidence suggests that antenatal hand expression was moderately associated with exclusive breastfeeding of newborns in the first twenty-four hours of life and during the initial hospital stay.23
Prior research has shown that prenatal breastfeeding education increases rates of breastfeeding and that many women are interested in antenatal breast expression to help prepare for breastfeeding. Current literature also suggests that antenatal hand expression can be safe in starting as early as 36 weeks’ gestation, but our study examined if antenatal breast expression starting as late as 39 gestational weeks would still have an impact on maternal confidence in breastfeeding and help increase initiation and exclusive breastfeeding rates in our patient population.