Sustaining Breastfeeding

1. Sustaining Breastfeeding Rhona J McInnes, Pat Hoddinott, Jane Britten, Leone Craig

2. The Research • A prospective study exploring the early infant feeding experiences of parents and their significant others during the first 6 months of life: what would make a difference? • Funded by NHS Health Scotland • Final report: http://www.healthscotland.com/documents/4720.aspx

3. The Research • Design: Serial interviews (n=220); approx every 4 weeks from late pregnancy - 6 months after birth • Sample: 36 women & 37 nominated significant others • Location: 2 geographically separate and contrasting areas of Scotland

4. Initial findings • Clash between idealism vs realism • The dominant goal driving feeding is not ‘ideal’ breastfeeding but family / mother/ baby wellbeing • Behaviour changes at key pivotal points • where families often perceive the only solution to restore well-being is to stop breastfeeding or start solids /other fluids.

5. The next stage • Aim: who had influenced feeding • Emergent: how feeding influenced • People were important (Significant others, SO) • Situations: perceptual & tangible • Feeding history: personal & vicarious (family, media, internet)

6. SO Summary • Large variation: a woman naming only herself - a max of 9 SOs • Primiparouswomen named more SOs than multiparous women • Health professionals named frequently (30/36) • Midwives by 13 espec prims (9/13) • Health visitors by 26 espec around solids

7. The influences Significant others, the self-baby dyad, situations and feeding history influenced decision-making could accelerate or decelerate feeding behaviour change Resolve behaviour change

8. “I could feel myself welling up because I had my heart set on getting out that day …that’s why I said we’d go on to the formula”

9. Resolving: after change • Women turned to SOs to dispel doubts or justify feeding changes • Confidence & self-esteem increased when someone said ‘you’ve done the right thing, that’s fine’ • Failure, guilt or remorse when SOs were disapproving or criticising

10. What do women and their families want?

11. Early PN period • The main priority is help to learn how to breastfeed in early days after birth • health professional time to observe and build confidence • Kindness, patience, reassurance, unrushed care preferred • Personality, communication skills & expert knowledge > professional rank or qualifications • Constructive relationship > directive “fixing” approach or enthusiastic persuasion • Emotional feelings as important as technical aspects eg positioning & attachment

12. the auxiliary nurse didn't have experience, she didn’t have the patience and she really didn't quite know what she was doing and she was just telling me what to do, she wasn't, you know, showing me what to do… and that just basically ruined the whole thing… (Breastfeeding stopped in 1stweek)

13. Early PN period Considerable change precipitated at this time • Situations & staff on PN ward important influence • Staff often too busy/missed opportunities to resolve emotional distress, give practical help • Staff anxiety transmitted: is baby getting enough? How long can he go without feeding? Weight loss? Crying baby? • Women feel isolated, partner not able to “share or support”

14. Precipitating change • I was under pressure to use the pump and to top up with formula, it’s almost like straight away and I wanted to try just using the breast only … I was just so upset at that point that I just wanted to get him food so I said just give me a bottle

15. Early PN period cont… • Unpredictable community midwifery care  tensions • Getting the right support at the right time to prevent pivotal points • Involve wider circle of family and friends in discussions  • More discussion on different feed options

16. Party lines and mixed messages They said that they prefer you to, before you start expressing, just to breastfeed for the first eight weeks because you don’t really want to confuse the baby between bottle and the breast you can’t express milk until the baby’s 12 weeks old, whereas others (MW) said 8 weeks another midwife, at one of the classes, she was saying well if after two weeks you want to express milk and give them it in a bottle then do it. It’s your baby, it’s like you do what suits you

17. Midwives can sustain BF • TIMEfrom skilled, women-centred (vsBF focused) midwives “They were able to dedicate somebody to sit with me". • Listen & encourage “always listens, she won't be negative if I say  I'm not sure how much longer I can feed him” • Give women permission not to be perfect “Fine, we call it a crisis bottle, nothing wrong with that” • Facilitating women’s choice

18. Key points • Family wellbeing feeding behaviour • rather than ideal feeding • Infant feeding influences • dynamic combination of people, situations, feeding history • Feeding pivotal points in 1st few days • precipitated by feeding difficulties & emotional distress • Women’s self-esteem • maintain by resolving behaviour change positively • Family centred approach • rather than targeting individual women • Rigid organisation of health services impedes timely woman-centred care

19. Publications • Final report: A prospective study exploring the early infant feeding experiences of parents and their significant others during the first 6 months of life: what would make a difference? http://www.healthscotland.com/documents/4720.aspx • Hoddinott P, Craig L, Britten J, McInnes RJ. A serial qualitative interview study of infant feeding experiences: idealism meets realism BMJ Open 2012; 2: e000504; doi 10.1136/bmjopen-2011-000504