Bigger Breastfeeding – Behind the Statistics

What is it?

As mammals, we’re designed to nurse our young.

Breastmilk is the perfect first food; attractively packaged, available on demand at the correct temperature, correct consistency, correct formulation for each stage and season, comes with no wasted packaging, food miles, additives or preservatives, and confers health benefits on both mother and baby.

Yet we and health professionals caring for us are being told that those with a BMI over 30

‘will need extra support with breast feeding’

(Countess of Chester Hospital policy – Information For Pregnancies With Increased BMI)

‘Obesity is associated with low breastfeeding initiation and maintenance rates. Women with a booking BMI ≥30 should receive appropriate specialist advice and support’

which leaves many women believing they will struggle to do one of the most natural things in the world for their babies.

Why?

This is because bigger women have been shown to be less likely to start breastfeeding, and are likely to give up nursing sooner than their ‘normal’ weight counterparts. The data comes from an Australian review of 27 individual studies on breastfeeding from around the world.

A systematic review of maternal obesity and breastfeeding intention, initiation and duration
Lisa H Amir and Susan Donath
http://www.biomedcentral.com/1471-2393/7/9

But why would this be the case? The review unfortunately comes up with no concrete conclusions as to the causes;

The reasons may be biological or they maybe psychological, behavioural and/or cultural.

Well, that just about covers all bases, doesn’t it?! It also offers no solutions, other than ‘we need more research’, but digging around within the review are some interesting results from individual studies.

What?

Previous research has shown that the strongest indicator of likely breastfeeding is the mother’s intention to breastfeed. Strange that.

In the Australian review we find that yes, obese women breastfed less, but in two out of three studies where the mother’s intent to breastfeed was measured, obese women intended to breastfeed less!

So, having a high BMI is an indicator that you may not breastfeed or feed for as long – if you didn’t want to in the first place! Not quite the case of bigger women struggling with breastfeeding, as we might be led to believe.

Why bigger women are less inclined to breastfeed is unknown, but surely telling bigger women that they’re less likely to breastfeed when the studies already show is that if you’re bigger you’re less likely to consider breastfeeding, could perpetuate the problem? There’s nothing like telling someone they’re going to fail to stop them from trying in the first place…

This also means that later statistics on the links between increasing BMI and decreasing breastfeeding are pointless on an individual level, if the difference is a ‘choice’ rather than due to some inherent deficiency the fatter you get.

Delayed milk production?

There is some talk of a link between obesity and delayed milk production in the review. Three out of five studies found a link, stating that delayed milk production was found in 33% of obese women, compared with 16% of ‘normal’ weight women. However, all of these studies were US based, and all with small sample sizes (between 40 and 280), which renders their results less reliable. But could there also be a reason for this unconnected with maternal weight?

One medical record review in the US found that obese women were less likely to put the baby to the breast in the first two hours after birth, important for generating the hormones needed to stimulate milk production. Again the reasons for this are unclear (and unmentioned in the study) but the greater use of interventions on bigger women may play its part; caesareans in general are associated with lower rates and duration of breastfeeding, and we know that bigger women are more likely to have caesarean deliveries. There may also be links with other interventions such as inductions, and epidurals, which again are more likely in bigger mums, especially in the USA. The studies don’t seem to have accounted for this.

If not putting the baby to the breast as soon as possible after delivery is significant in affecting milk production, then it may be that the current model of care for bigger women itself is actually having a detrimental affect on breastfeeding initiation and duration rates.

Medical Conditions?

Something which may feasibly affect lactation are medical conditions, particularly Poly Cystic Ovary Syndrome (PCOS) and Diabetes, both of which alter hormone production in the body and disproportionately affect larger women.

But the only medical condition the review touches upon for which there is some evidence of a detrimental affect on breastfeeding is depression. One study found that depressed women are less likely to continue breastfeeding than non-depressed women, and another study found that obese women are more likely to experience post-natal depression.

For diabetes, the review refers to one very small study (just 38 women) which found that diabetic mothers milk seemingly transitioned from the first milk (colostrum) to ‘normal’ breastmilk later than women who did not have diabetes, but did not follow up on whether this impacted upon breastfeeding as a whole.

For Poly Cystic Ovary Syndrome, the review found an article based on an even smaller sample; just 3 cases, which hypothesised that Poly Cystic Ovary Syndrome may be associated with insufficient milk supply. To say that there is a paucity of evidence on the effects of these two conditions on lactation is to understate the situation considerably.

The best the review can manage in drawing a link between obesity and reduced lactation is via animal studies. I’ve been called a fat cow in the past, but I never expected to be compared to one!

Breasts too big?

The review mentions that historically, having large breasts was associated with producing poorer quality milk, or not enough milk. Fortunately, this appears to be an old wives’ tale, and if anything, recent research has shown that obese women were actually less likely to cite ‘poor milk supply’ as a reason for stopping breastfeeding.

One study referenced by the review found that obese women tended to have greater body image dissatisfaction compared with non-obese women, and another study found that women with increased concern about their body shape or weight were less likely to intend to breastfeed. So all the more reason to stop the negativity around bigger women breastfeeding, no?

It is suggested that having bigger breasts may lead to difficulties to latching on a baby due to nipple size, shape, and location, supporting the breast while latching on, not being able to see the nipple/areola while attempting to latch on, and the weight of the breast pushing against the baby’s chest while feeding. Again, no decent evidence to back this up, though.

There is plenty of information and advice available on the mechanics of breastfeeding for those who seek it, big boobed or otherwise. One often suggested solution for mums with big boobs and/or tummies who find the usual cross-cradle isn’t suitable for them, is to try alternative holds such as the unfortunately named ‘rugby ball’, or feed while lying down. For every problem there is a solution. That solution doesn’t have to be formula.

Alternatively…

If you’re looking for positive information about obese women breastfeeding, the review does find that studies in Russia and Denmark found no difference in breastfeeding duration in obese mothers; in the indigenous populations of Canada, rates of both obesity and breastfeeding are higher; and in Kuwait, higher maternal weight was actually associated with a longer duration of breastfeeding!

So if you intend to breastfeed, don’t take the scaremongering to heart. If you do encounter any problems with breastfeeding, don’t assume that it has anything to do with your size.

Breastfeeding is a skill which used to be passed down through the generations. In the past, when breastfeeding was commonplace, the support network available was huge. Unfortunately in the last few decades this was undermined, and the skill, and the community support for it, was lost to some extent, although it is slowly being rebuilt.

Like any skill, how to breastfeed needs to be learnt and perfected.

Many many women of all sizes and shapes experience niggles, but the actual number of women who are truly unable to breastfeed is estimated to be very low – perhaps as low as 4%.

Sources of Information and Advice

There is a wealth of advice, information and support available; you can watch YouTube videos on positioning and attachment, different holds and the like; you can attend breastfeeding groups and cafés where trained helpers can support you; you can call the National Breastfeeding Helpline, you can contact La Leche League, The National Childbirth Trust, Association of Breastfeeding Mothers, the Breastfeeding Network, or an International Board Certified Lactation Consultant (IBCLC), or you can read a wealth on information on the topic on the NHS webpages, Kellymom and Analytical Armadillo.

The help is out there… Unfortunately, I’m not aware of any big-boob specific information in the public domain right now. I know it would be really helpful to have some kind of guide to logistics and positions which feature bodies which look more similar to mine! If you find or know of any, please do get in touch so I can let people know!!

References

CMACE/RCOG Joint Guideline Management of Women with Obesity in Pregnancy
March 2010

A systematic review of maternal obesity and breastfeeding intention, initiation and duration
Lisa H Amir and Susan Donath
http://www.biomedcentral.com/1471-2393/7/9

Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study
Lisa H Amir and Susan Donath
https://pubmed.ncbi.nlm.nih.gov/12725552/

Breast-feeding and its relation to smoking and mode of delivery
Gabriel M Leung, Tai Hing Lam, Lai Ming Ho
https://pubmed.ncbi.nlm.nih.gov/11978288/

Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey
S Jordan, S Emery, A Watkins, JD Evans, M Storey, G Morgan
https://pubmed.ncbi.nlm.nih.gov/19735379/

Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding
Heather J Rowe-Murray, Jane R W Fisher
https://pubmed.ncbi.nlm.nih.gov/12000413/

Milk lactose, citrate, and glucose as markers of lactogenesis in normal and diabetic women
P G Arthur, M Smith, P E Hartmann
https://pubmed.ncbi.nlm.nih.gov/2621526/