Breastfeeding is important to child survival, nutrition and development and maternal health (1). The World Health Organization (WHO) recommends exclusive breastfeeding for babies to six months of age to achieve optimal growth, development, and health. Thereafter, the continuation of breastfeeding is recommended for at least two years, together with complementary foods (2). The WHO recommendations provide strong evidence, however, there are marked variations in breastfeeding rates among regions and women of different population groups. Of particular importance, breastfeeding rates are suboptimal among some 'at risk' groups, such as women with type 1 diabetes (T1D) and type 2 diabetes (T2D) (3) and these women also tend to breastfeed for a shorter duration than other childbearing women (4, 5, 6, 7). A recent Australian study found that compared with women with no hyperglycaemia in pregnancy, women with T2D had lower odds for exclusive breastfeeding at discharge, at 6 weeks and 6 months (8).
The major determinant for breastfeeding on discharge from maternity hospital among women with pre-existing diabetes is that their babies are breastfed their first feed (9). Despite this, breastfeeding initiation rates are often lower among women with pre-pregnancy diabetes compared to women with gestational diabetes and women without diabetes (10–12). Multiple factors impact on breastfeeding rates in women with diabetes.
Infants of women with pre-pregnancy diabetes are at higher risk of complications such as macrosomia, hypoglycaemia and congenital abnormalities (13). In addition, mothers with diabetes have higher rates of complications during pregnancy and delivery, such as preeclampsia and caesarean section and their infants are more likely to need admission to Neonatal Intensive Care Unit (NICU) and Special Care Nursery (SCN) units (14). Infants of mothers with diabetes also often have a more immature sucking pattern than infants of mothers without diabetes (15) and women with diabetes commonly experience difficulties with milk supply (16, 17), delayed lactation and fluctuating maternal blood glucose levels (19).
Women with diabetes may also be concerned about their own health (15) as well as the impact of their diabetes on the new baby (16). Some of the challenges experienced by women with diabetes in the early postpartum period may make it difficult for them to breastfeed and simultaneously maintain optimal blood glucose levels (17), particularly at night (18, 20). Acknowledgment of their effort, and encouragement of support from partners, families and friends is important (21).
Women who have diabetes and a newborn baby are often socially isolated and fearful of developing a hypoglycaemic episode while nursing their baby (18, 22). The use of technology to connect women with others in similar situations has proven to be beneficial and to enhance women’s quality of life (23). In 2018, 88% of Australians were active users of the internet (24). Online technology, support and resources offer women with diabetes an affordable, easily accessible and familiar way of communicating and connecting with other women with pre-pregnancy who have also recently given birth. Technology can supplement usual diabetes care by providing educational and motivational support, especially as Australians increasingly access the internet and mobile devices (24), this increases the opportunities for HPs to engage with clients via technology.
Previous research has concluded that it is not diabetes itself, but factors associated with diabetes that explain the early cessation of breastfeeding (19, 25). In a British retrospective cohort study using maternal records and postal questionnaires in women with T1D and T2D it was found that getting the balance right between support and coercion could be a challenge as the perception of support versus pressure depended on the individual woman (26). Similarly, a Swedish qualitative study highlighted that even though support from health professionals (HPs) was valued, conflicting breastfeeding advice was an issue for women (19). The authors advocate for clear communication between midwives, diabetes educators and diabetes specialists so that mothers can receive consistent, informed and timely responsive support to meet their information needs with regards to managing breastfeeding, diabetes and infant needs (25). Women may also have specific needs such as practical help to manage daily activities with an infant, their diabetes and breastfeeding. Women may also feel that their HPs do not and they may also have specific needs such as practical help to manage daily activities with an infant, their diabetes and breastfeeding to provide them with adequate breastfeeding knowledge, skills and support (17, 18) and they may also have specific needs such as practical help to manage daily activities with an infant, their diabetes and breastfeeding, There is a lack of current breastfeeding information and support resources tailored for women with diabetes-specific needs and requirements.
This study had three aims: 1. to identify the educational and support needs of women with T1D and T2D who intend to breastfeed, are currently breastfeeding or had recently breastfed; 2. explore HPs’ perspectives of the educational and knowledge/information needs of women with diabetes who intend to breastfeed or are currently breastfeeding; and 3. develop a resource that addresses women’s preferences and needs and is informed by the diabetes HPs views and from the perspectives of women with T1D or T2D.