Shared decision making and breastfeeding: Supporting families’ informed choices

British Columbia has the highest rates of breastfeeding initiation in Canada, but there is a sharp decline in breastfeeding in the weeks or months after birth.[1] Supporting families in making difficult infant feeding choices in a nonjudgmental way can support the health of infants and may help increase breastfeeding rates by improving the therapeutic relationship with health care professionals. While promotion of exclusive human-milk feeding is well intentioned and based on evidence that it confers more health benefits for parents and infants compared to formula,[2] a family’s context and choices are sometimes overlooked. Breastfeeding may not be the optimal choice at a given time due to early return to work, history of smoking or drug use, and other far-reaching socioeconomic reasons.[3,4] When families choose infant feeding options other than exclusive human milk, they frequently experience guilt, shame, and failure, which can create mistrust with their health care professionals.[5] In this context, health care professionals may need more support to engage in complex discussions that promote breastfeeding while simultaneously offering safe, informed choices of alternate feeding options.

Developing health care professionals’ skills in shared decision making is one solution. Shared decision making is a form of non­directive counseling where the professional and patient come together as experts, in clinical evidence and lived experience respectively. This division of power shifts the conversation from giving patient education to exchanging information to help the family reach their goals.[6] The ideal result of a shared decision-making process is a patient decision that is informed, consistent with their personal values, and acted upon.[7]

The BC Centre for Disease Control, in partnership with researchers from UBC and the Centre for Health Evaluation and Outcome Sciences, has been developing shared decision-making skills education for health care professionals to better support infant feeding choices. To date, our interview study and literature review have explored BC health care professionals’ and families’ needs in making infant feeding decisions from pregnancy to 6-months postpartum.

We learned that BC health care professionals begin infant feeding discussions with questions to gain information about the family (“Do you plan on breastfeeding?”), not for the family to gain clarity about their goals and what matters most to them. They also centred the conversation on newborn health, such as weight gain milestones, which can ignore related concerns that influence parents’ infant feeding choices. Existing communication and counseling approaches used by BC health care professionals (e.g., trauma-informed care, motivational interviewing) can underpin the development of shared decision-making skills.

Training in shared decision making for health care professionals is well established in other parts of Canada, and in the next phase of our collaboration we will bring a program to BC. It will include experiential learning, practical cases, cultural safety techniques, strategies for building rapport with families, and educational credits.
—Sarah Munro, PhD
UBC, Centre for Health Evaluation and Outcome Sciences (CHÉOS)
—Cynthia Buckett, MBA, RD
BCCDC
—Julie Sou, MSc
CHÉOS
—Nick Bansback, PhD
UBC, CHÉOS
—Henry Lau, RD
BCCDC

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This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Statistics Canada. Breastfeeding trends in Canada. 2013. Accessed 29 October 2019. www150.statcan.gc.ca/n1/pub/82-624-x/2013001/article/11879-eng.htm.

2.    Dieterich CM, Felice JP, O’Sullivan E, Rasmussen KM. Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin North Am 2013;60:31-48.

3.    Radzyminski S, Callister LC. Mother’s beliefs, attitudes, and decision making related to infant feeding choices. J Perinat Educ 2016;25:18-28.

4.    Fischer TP, Olson BH. A qualitative study to understand cultural factors affecting a mother’s decision to breast or formula feed. J Hum Lact 2014;30:209-216.

5.    Thomson G, Ebisch-Burton K, Flacking R. Shame if you do—shame if you don’t: Women’s experiences of infant feeding. Matern Child Nutr 2015;11:33-46.

6.    O’Connor AM, Légaré F, Stacey D. Risk communication in practice: The contribution of decision aids. BMJ 2003;327:736-740.

7.    Légaré F, Stacey D, Pouliot S, et al. Interprofessionalism and shared decision-making in primary care: A stepwise approach towards a new model. J Interprof Care 2011;25:18-25.