I have written several other posts on this topic in the past so you can
check the archives if you care to see what I said then (haven't changed my
opinion since).
I don't think I mentioned the MIDIRS series of leaflets on informed choice
last time round.  This series, produced by a non-profit foundation devoted
to the dissemination of research findings in order to improve maternity
care, has been given an award for clarity of language and quality of
information.  They are available at reasonable cost from MIDIRS
(www.midirs.org) and cover a range of topics, including epidurals and
breastfeeding, though not in the same leaflet.

There isn't any research to speak of which looks at the effects of epidurals
on BF.  So, a hospital requiring prenatal educators to state that there is
no evidence linking epidurals to BF failure is not encouraging lies.  But it
would be more informative, not to mention more honest, to say there is no
research investigating the relationship of epidurals to BF failure.  The
research on the effects of epidurals on newborn behavior is also sparse, but
does exist.  Unfortunately most of it seems to have been done in a time when
BF was not viewed as an interesting outcome parameter, and in places where
BF was not the norm anyway.

There is, however, ample research linking epidurals to increased rates of
operative delivery.  The basics of BF support the first days post partum are
ensuring a comfortable BF position for the mother, and keeping her and baby
close together.  Anything at all that makes that harder, should be something
we inform women about.  Does it really need to be stated, or proven, that it
is better for the baby to have a mother who is up and about and in no need
of analgesia, than a mother who can't turn over in bed unaided and is
dependent on narcotics to have a modicum of comfort?  Kathy Dettwyler
pointed out that the burden of proof should be on those proposing deviations
from normal, to prove that their intervention is not harmful.

We can't get subjective answers from the babies about their experiences of
instrumental delivery or CS-- unfortunately.  I feel that the evidence from
the mothers is more than enough to make us take notice, and not just for the
sake of BF.  It is impossible to separate baby-friendly and mother-friendly
practice.

Again I repeat that no one factor (short of infant or maternal death), is
enough to put an end to BF.  The sum of all the factors determines BF
outcome.  The more obstacles there are to normalcy, the more it is necessary
to have support in place to prevent snowballing of negative effects.  The
MIDIRS leaflet on epidurals encourages women to ask hospitals about their
rates of normal birth in women having epidurals.  They could also ask
hospitals about rates of BF problems in the epidural group, and how this
compares with rates for women not having epidurals.  My guess is that most
hospitals haven't got a clue, and that alone should make us ask more, not
less questions.

Rachel Myr
Kristiansand, Norway

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