Breastfeeding after a caesarean section : mother-infant health trade-offs

This thesis demonstrates the value of an anthropological perspective on informing appropriate breastfeeding support after caesarean section delivery. In contrast to epidemiological research that identifies distinct aspects of mother-infant interactions altered by this birth mode, my research explored the interrelated obstacles to breastfeeding from the mothers’ perspectives as the experiences were unfolding. I apply Trivers’s (1974) parent-offspring conflict model to conceptualise breastfeeding and predict realisation of infant feeding based on the interaction of maternal cost and infant benefit. The work adds the previously unstudied population of caesarean section-delivered breastfeeding dyads to the human life-history theory line of investigation. Postnatal ward and telephone semi-structured interview data were collected in Newcastle, England during 2006-09 with two groups of women. Phase 1 comprised participants who underwent either an unscheduled or scheduled caesarean section delivery (n = 75). Phase 2 involved women who experienced scheduled, non-labour caesarean section delivery and were randomly allocated an intervention or control cot for the entirety of their postnatal ward stay (n = 51). The impact of the infant side-car crib or standalone cot on breastfeeding was tested among the Phase 2 mothers by comparison of 35 overnight postnatal ward video recordings. The various aspects of women’s delivery and infant care were prioritised based on their knowledge of known risks and benefits. Intentions were carried out within the context of the support and opportunities available. Contrary to popular belief, the decision to undergo a caesarean section and deviation from prenatal breastfeeding intentions were undertaken because they seemed like the best or only option in the circumstances. Many women felt frustrated because of their postnatal limitations with caretaking for infants who were described as unexpectedly doing poorly. The absence of labour before the caesarean section was perceived to be beneficial by the mothers due to the intense pain of contractions and the undo “stress” vaginal parturition posed for the infant. However, the participants were surprised by being told by midwives after the delivery that (sub-clinically) poor infant condition was a common consequence of caesarean section. Some breastfeeding difficulty stemmed from “mucous” expulsion that had to occur before the babies could be “interested” in feeding. The peak mother-infant breastfeeding conflict was night-time after visiting hours. Midwifery and maternal concerns over the mothers’ lack of sleep prompted formula supplementation. As predicted, the side-car crib was associated with reduction of the maternal cost of breastfeeding. However, participants in the intervention group were not observed breastfeeding significantly more frequently than the control group as expected. The cost-benefit breastfeeding model suggests that high maternal cost and/or low perceived infant benefit was experienced to such a degree that mothers breastfed minimally despite the “huge difference” in infant access afforded by the side-car crib compared to the standalone cot. Regardless, data support the side-car crib as the better arrangement for mother-infant dyads who underwent a non-labour caesarean section due to the less potential infant risk observed and the benefit to maternal recovery. The utility of the parent-offspring conflict framework for predicting breastfeeding outcomes was supported by the association of reported reasons for breastfeeding intent and of bedsharing with breastfeeding frequency and duration. The thesis suggests that more detailed physiological information may enable families to better understand public health advice for exclusive breastfeeding and low caesarean section delivery rates. Breastfeeding after a caesarean section is affected by interrelated and compounding difficulties, so my single alteration in the postnatal environment did not resolve the impediments. An evolutionary perspective can assist in identifying populations at risk for suboptimal health outcomes and designing support to ameliorate mismatches between coevolved processes and routinely encountered conditions.