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    <meta name="author" content="Denise Fisher" />
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      <h1 id="top">3.2 The barriers</h1>
      <div>
    <p class="listTitle">Barriers to breastfeeding can be divided into 3 main categories:</p>
    <ul>
      <li><strong>societal barriers,</strong> such as attitudes of the general population, the mother and her support networks. These are influenced by commercial interests, among other things.</li>
      <li><strong>health professionals</strong> who lack knowledge, skills and management of breastfeeding</li>
      <li><strong>postnatal perceptions</strong> of ability to continue breastfeeding. The mother's lack of knowledge of normal newborn behaviour, breastfeeding management and a need or expectation to work away from her baby influence this perception.</li>
    </ul>
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              <h3>Workbook Activity 3.2</h3>
              <p>Complete Activity 3.2 in your workbook.</p>
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      <div class="section" id="Societal_barriers"><h2>Societal barriers</h2>
    <div>
      <p>
		Worldwide campaigns, eg. World Breastfeeding Week, a WABA initiative; the Global Strategy for Infant and Young Child Feeding, a WHO/UNICEF initiative, as well as national and local initiatives attempt to influence community attitudes.
	</p>
    </div>
    <div class="captionBox"><img width="400" height="268" src="images/billboard_born2Bbreastfed.jpg" alt="National program to influence community attitudes.       The Ad Council, USA" /><p>National program to influence community attitudes.       The Ad Council, USA</p></div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="250" height="255" src="images/bfing_welcome250.gif" alt="from San Diego County Breastfeeding Coalition" /><p>from San Diego County Breastfeeding Coalition</p></div>
      </div><div class="column" style="width: 50%">
        <div>Acceptance of breastfeeding in public is a reflection of community attitudes. Discomfort in public breastfeeding is reported by many women and is noted as a significant barrier. Targeting this area specifically, organizations have developed public service announcements for various media.<br />Some countries and States have had to go to the extreme step of legislating for a mother's right to breastfeed her baby wherever she and her baby are when her baby requires feeding.</div>
      </div></div><br style="clear: both" />
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>What can you do to influence community attitudes?</h3>
      <div>
        <p> Before you can address barriers that mothers will have to overcome, you will need to understand what they are. Surveying the mothers and their relatives and friends that you meet in your unit could give you a starting point. From there, a small but enthusiastic committee could brainstorm ideas for local and community activities to address these concerns. <br /></p>
        <p>Share your findings in the forum.<br /></p>
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      <div class="section" id="Health_provider_knowledge_skills_and_management"><h2>Health provider knowledge, skills and management</h2>
    <div>
      <p> A common complaint from women is the amount of conflicting advice they receive from their health care providers. Also some of that advice may be detrimental to ongoing breastfeeding success. </p>
      <br />
    </div>
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        <div class="section" id="Step_1_and_Point_1"><h3>Step 1 and Point 1</h3>
          <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
            <div><span style="font-weight: bold;">Step 1</span> of the <span style="font-style: italic;">Ten Steps to Successful Breastfeeding</span> and<span style="font-weight: bold;"> Point 1</span> of the <span style="font-style: italic;">Seven Point Plan for Sustaining Breastfeeding in the Community </span>both state:</div>
            <blockquote>
              <div>
                <span style="font-style: italic;">Have a written breastfeeding policy that is routinely communicated to all staff</span>
              </div>
            </blockquote>
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          <div>
            <p> The policy should be displayed in all areas which serve mothers and babies and should cover all Ten Steps to Successful Breastfeeding in hospitals or all the Seven Point Plan, and prohibits the display or distribution of materials which promote breastmilk substitutes, feeding bottles, teats/artificial nipples and dummies/pacifiers. </p>
            <p class="listTitle">Having a written breastfeeding policy</p>
            <ul>
              <li>will eliminate the conflicting advice that is given to mothers; <span class="aside">All staff will be aware of what they must do.</span></li>
              <li>provides a stimulus for discussion for mothers<br /></li>
            </ul>
          </div>
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        <div class="captionBox"><img width="250" height="334" src="images/10_Steps_maori.jpg" alt="Display the Policy in the most common languages spoken." /><p>Display the Policy in the most common languages spoken. <br />&copy; D.Fisher, IBCLC</p></div>
      </div></div><br style="clear: both" />
    <div class="section" id="Baby_Friendly_Step_2_and_Point_2"><h3>Baby Friendly Step 2 and Point 2</h3>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
        <div><span style="font-weight: bold;"> Step 2 </span> of the <span style="font-style: italic;"> Ten Steps to Successful Breastfeeding </span> and <span style="font-weight: bold;"> Point 2 </span> of the <span style="font-style: italic;"> Seven Point Plan for Sustaining Breastfeeding in the Community </span> both state:</div>
        <blockquote>
          <div>
            <span style="font-style: italic;">Train all health care staff in skills necessary to implement this breastfeeding policy</span>
            <br />
          </div>
        </blockquote>
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      <div>
        <span style="font-weight: bold;">Congratulations on joining the ever-growing group of skilled and knowledgeable health professionals who protect, promote and support breastfeeding mothers and babies!</span>
        <br />
      </div>
    </div>
  </div>
      <div>
    <p>Education of health professionals using the curriculum developed for Step 2 of the Baby Friendly Hospitals Initiative produced staff who were significantly more knowledgeable about breastfeeding, had more positive attitudes and were more likely to employ correct practices for the promotion of exclusive breastfeeding.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup> Another study showed that mothers who birthed in hospitals that had a high compliance to Baby Friendly Steps initiated breastfeeding in greater numbers and breastfed for longer than those in non-Baby Friendly hospitals.<sup><a href="#note3">3</a></sup> </p>
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            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Support your colleagues</h3>
    <div><span style="font-weight: bold;">ALL</span> of your colleagues want to do what is best for both mother and baby. Encourage those colleagues who are unsure of current, evidence-based practices to complete an educational program such as this one. It will help them to achieve their goal, and benefit mothers and babies.<br /></div>
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      <div class="section" id="Postnatal_perceptions"><h2>Postnatal perceptions</h2>
    <div>
      <p>
		Educating mothers about maintaining milk supply and normal newborn behaviour will be discussed as you work through this course.
	</p>
      <p>
		An increasing number of women spend large amounts of time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.
	</p>
    </div>
    <div class="section" id="Breastfeeding_and_separations"><h3>Breastfeeding and separations</h3>
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        <div></div><div class="activity" id="activity_c">
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	{ c : '<p>\n				Many women feel they have to wean completely when they return to work. However there are numerous options they can consider. List as many options as you can think of for a mother to continue to provide breastmilk to her baby after a return to employment outside the home.\n			</p>', r : '<ol><li>Reduce her working hours, or work mostly during baby\'s sleep time (eg. a night shift) so that she is not absent for breastfeeds.</li><li>Take the baby to work with her.</li><li>Have the baby cared for close enough for her to visit and breastfeed during her work breaks.</li><li>Have the child\'s carer bring him/her to her place of work when breastfeeding is required.</li><li>Express (pump) breastmilk each day to leave with the carer to give.</li><li>Breastfeed frequently when together, but have the carer give artificial infant formula.</li><li>If baby is older than 6 months, have carer give small amounts of complementary foods.</li></ol><p> What other alternatives did you think of? </p>' }
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      <div>
        <p class="listTitle">Leaving her baby to go to work can be a highly stressful time for the mother. She will need to consider the physical and emotional effects of separation for long or short periods of time. <br /></p>
        <p class="listTitle">Continuing to provide breastmilk can</p>
        <ul>
          <li>present many challenges,</li>
          <li>help her to maintain an emotional connection to her baby, despite her physical absence,</li>
          <li>avoid the acute and chronic illnesses associated with artificial infant formula,</li>
          <li>make breastfeeding when they are reunited a very special and close time.</li>
        </ul>
        <p class="listTitle">Your professional role is to</p>
        <ul>
          <li>Educate her on the value of continuing to provide breastmilk for her baby, despite separation.</li>
          <li>Discuss the issues she will need to address to be successful.</li>
          <li>Provide her with contacts for peer-support services, to talk with other women in her situation.</li>
          <li>Inform the mother of her right to breastfeed, and what workplace legislation will protect her right.</li>
        </ul>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Do some action research</h3>
        <div>
          <p>
			Ask your colleagues, friends and the mothers you meet who continued to breastfeed until their baby was at least 12 months old what they did during periods of separation. You are likely to get many unique ideas which you can share with pregnant women.
		</p>
        </div>
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  </div>
      <div class="section" id="Breastfeeding_in_special_circumstances"><h2>Breastfeeding in special circumstances</h2>
    <div>
      <p>
		Most women will be healthy, having no special needs regarding breastfeeding, and will be able to breastfeed without difficulty.
	</p>
    </div>
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	{ c : '<p>\n				List the special circumstances that some women may have that will require additional counseling time.\n			</p>', r : '<p>\n				The following is a suggested list of women you may have identified. Your local area will have its own specific needs as well.\n			</p><ul><li>Had difficulties breastfeeding a previous baby; weaned very early or never started breastfeeding.</li><li>Must spend time away from her baby for employment or school.</li><li>Has non-supportive family members.</li><li>Is depressed, or previously had post-natal depression.</li><li>Is isolated, without social support.</li><li>Is a young or single mother.</li><li>Has had breast surgery or trauma.</li><li>Has a chronic illness or needs medication.</li><li>Is at high risk of baby needing special care, or has a multiple pregnancy.</li><li>Is tested and shown to be HIV-positive.</li><li>Has a physical, visual or auditory disability.</li></ul>' }
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    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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      <div>
        <p>
			In some of the circumstances described the mother will need the help of other health professionals, such as a psychologist, or a lactation consultant, or a doctor, and perhaps referral to a peer-support group. Does your Unit have a procedure in place to ensure the mother is aware of these other services and able to access them?
		</p>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <p> Addressing the following barriers will make breastfeeding possible for more women. </p>
        <ul>
          <li>Barriers caused by her health professionals who may lack knowledge or have routine practices that are detrimental.</li>
          <li>Attitudes of her family, friends and the society in which she lives. These are often formed by commercial interests.</li>
          <li>The mother's perception of her ability to breastfeed either physically or in her particular circumstances.</li>
        </ul>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#gupt02" title="See full details">#</a> Gupta A et al. (2002) Training in Baby Friendly Hospital Initiative</li>
          <li id="note2"><a href="references.html#owoa02" title="See full details">#</a> Owoaje ET et al. (2002) Previous BFHI training and nurses' knowledge, attitudes and practices regarding exclusive breastfeeding</li>
          <li id="note3"><a href="references.html#mert05" title="See full details">#</a> Merten S et al. (2005) Do baby-friendly hospitals influence breastfeeding duration on a national level?</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li class="current">3.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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