Support needs of breast-feeding women: views of Australian midwives and health nurses

Thoughts and experiences of well-educated fathers about their role when breastfeeding difficulties arose

OBJECTIVE

To investigate how fathers or partners perceive their roles as new parents when confronted with early breastfeeding challenges, how they navigate these difficulties, and the specific type of support they seek from the Child Health Care Centre (CHCC).

METHOD

In-depth, individual interviews conducted with 12 partners of women for whom breastfeeding was difficult. Reflexive thematic analysis was applied on the interview data.

RESULTS

Interviews resulted in three themes: 1) 'It is a revolutionary time to be a new father' represented a tumultuous time when fathers wanted to be involved in all decisions and part of a strong team with their partners. 2) 'When a breastfeeding problem arose'; fathers questioned the sovereignty of breast milk and began to seek more knowledge. They experienced a strong social norm about breastfeeding that led to feelings of guilt for their partners. They felt helpless when their partners suffered and lacked support. 3) 'Child Health Care Centre's duty'; was instrumental, as knowledge and competence were found to be important for trust. The fathers wanted concrete solutions to breastfeeding problems and more conversations of support with the CHCC nurse.

CONCLUSION

Well-educated fathers desire to protect their partners as they experience suffering due to a robust social norm telling them that breastfeeding is best. This can result in them starting to question the sovereignty of breast milk. Fathers need support to help their partners successfully during breastfeeding. They want counselling to strengthen their role as parents and help them build trusting teams with their partners.

Healthcare providers' perceived barriers to providing breastfeeding support in Northwest rural China

BACKGROUND

Healthcare providers play important roles in supporting breastfeeding. Although there has been insufficient actual breastfeeding support from healthcare providers in China, little research has been conducted to understand Chinese healthcare providers' perceived barriers to providing breastfeeding support, especially in rural China. This study aims to identify these perceived barriers to providing breastfeeding support in Northwestern rural China.

METHODS

This study was conducted during the period from March 2018 to December 2018. Forty-one healthcare providers were recruited through purposive sampling in two rural counties in Northwest China that are in close proximity to each other and share similar demographic features. Participants included obstetrician-gynecologists, midwives, nurses, "village doctors", and township and village maternal and child health workers. Qualitative data were collected through one-on-one in-depth semi-structured interviews and focus group discussions. Transcripts were thematically analyzed.

RESULTS

Analysis of interview data resulted in four themes that the participants perceived as barriers to supporting breastfeeding: (1) lack of medical resources, within which inadequate staffing, and lack of financial incentives were discussed, (2) lack of clear and specific responsibility assignment, within which no one takes the lead, and mutual buck-passing were discussed, (3) healthcare providers' lack of relevant expertise, within which lack of knowledge and skills, and low prestige of village healthcare providers were discussed, (4) difficulties in accessing mothers, within which medical equipment shortages reduce services utilization, mothers' housing situation, mothers' mobility, and cultural barriers were discussed.

CONCLUSIONS

The study identified HCPs perceived barriers to providing breastfeeding support. Unique to China's Tri-Level Healthcare System, challenges like staffing and financial incentives are hard to swiftly tackle. Recommendations include mHealth enhancement and clarified responsibilities with incentives and tailored training. Further research is crucial to evaluate these strategies in rural Northwestern China and comparable underdeveloped areas nationwide.

Being connected: Exploring the needs of mothers during the postnatal period in Queensland, Australia

This project explored the needs of mothers beyond the immediate postnatal period in Queensland, Australia, for the development of improved models of care. Data were collected through group and individual interviews. A qualitative methodology using thematic analysis captured the experience of 58 participants. Four key themes were generated: Caring for self, Being connected, Getting direction and Having options. Being connected with care providers and peers was highly valued by participants as was having a sense of direction. Having a relationship with a carer who knew them personally throughout pregnancy and postnatal care avoided retelling stories and facilitated information sharing. Relationship-based care enabled mothers to better meet their personal needs necessary to fulfil the parenting role. Yet, many points of disconnect were identified including inconsistencies in information and gaps in care. These findings demonstrate a range of unmet needs, situated within a lack of relational continuity. Maternity and child health professionals, service managers and policy makers must reorient systems by listening, acknowledging and keeping the voice of mothers at the centre of care.

Psychosocial predictors of post-natal anxiety and depression: Using Structural Equation Modelling to investigate the relationship between pressure to breastfeed, health care professional support, post-natal guilt and shame, and post-natal anxiety and depression within an infant feeding context

High perceived pressure to breastfeed and poor perceived quality of health care professional support have been associated with early breastfeeding cessation, guilt, and shame. This is problematic because guilt and shame significantly predict post-natal anxiety and depression. No previous attempts have been made to provide quantitative evidence for relationships mapped between the post-natal social context, infant feeding method and post-natal emotional well-being. The current study aimed to empirically investigate aforementioned pathways. Structural equation modelling was applied to survey data provided online by 876 mothers. Guilt and shame both significantly predicted anxiety and depression. Poor health care professional support and high pressure to breastfeed increased anxiety and depression, and these effects were explained by indirect pathways through increases in guilt and shame. Formula feeding exclusivity was negatively correlated with post-natal anxiety symptoms. This finding may be explained by feelings of relief associated with observed infant weight gain and being able to share infant feeding responsibilities others e.g., with one's partner. This relationship was counterbalanced by an indirect pathway where greater formula feeding exclusivity positively predicted guilt, which increased post-natal anxiety score. While guilt acted as mediator of infant feeding method to increase post-natal depression and anxiety, shame acted independently of infant feeding method. These identified differences provide empirical support for the transferability of general definitions of guilt (i.e., as remorse for having committed a moral transgression) and shame (i.e., internalisation of transgressive remorse to the self), to an infant feeding context. Recommendations for health care practitioners and the maternal social support network are discussed.

Web 2.0 as a new support for breastfeeding: Perception of mothers and professionals through a qualitative approach

OBJECTIVE

The objective of this paper is to explore the influence of Web 2.0 as a complementary support network to traditional networks for the promotion of breastfeeding (BF).

METHOD

Qualitative and exploratory study carried out from September 8 to December 31, 2022, at the Las Vegas Health Centre (Corvera), Health Service of the Principality of Asturias (SESPA). The participants were 5 professional experts in BF and 7 breastfeeding mothers, who made up two focus groups, selected by convenience sampling. The analysis consisted of transcription of data, in-depth reading, analysis by grouping concepts and classification of the information into categories.

RESULTS

After the final analysis, seven categories were identified, organised according to the proximity of the topic and the proposed objective, based on the most significant discourses of the study: difficulties during BF, importance of receiving help: first support networks, other support networks, A health system with deficiencies, pandemic and BF 2.0, Health 2.0 and apps in BF: new form of support and characteristics of an "ideal" app on BF.

CONCLUSIONS

Web 2.0 has revolutionised the way mothers access information and support on BF, creating an online support network connecting mothers and professionals around the world, providing up-to-date information and enabling a source of emotional support through the creation of peer groups. This positive influence of Web 2.0 has had a significant impact on promoting BF and empowering mothers to make informed decisions about their breastfeeding process.

A qualitative analysis of women's postnatal experiences of breastfeeding supports during the perinatal period in Ireland

Ireland has among the lowest rates of breastfeeding worldwide. Despite policies to support breastfeeding, breastfeeding initiation and exclusivity remain low in Ireland. Greater knowledge about support received in the maternity unit may-in part-shed light on why this is so. Our aim was to analyse women's experiences of the breastfeeding supports available in the early postnatal period in Ireland. We conducted an analysis of an open-ended question on a cross-sectional survey about breastfeeding support conducted in the Republic of Ireland in 2022. Participants were asked to provide comments about the breastfeeding support they received in the maternity unit or during your home birth. Data were analysed using Braun and Clarke's six-step Thematic Analysis Framework. There were 5,412 unique responses to the survey and 2,264 responses to the question of interest. Two themes were generated from the data: (i) 'Breastfeeding support in theory but not in practice.' Although breastfeeding was promoted by healthcare professionals antenatally, breastfeeding challenges were rarely mentioned. Participants then felt unsupported in overcoming challenges postnatally. (ii) 'Support was either inaccessible due to lack of staff/time, inadequate; i.e., unhelpful or non-specific, and/or physically inappropriate.' Most participants described receiving supports that were less than optimal in aiding them to establish breastfeeding. While many described difficulties in accessing supports, others found support to be 'non-specific,' 'rushed' and sometimes 'rough.' A lack of knowledge, time and support from healthcare professionals was frequently described, which was often recognised as a failing of the healthcare system. Women require practical, informative, and specific breastfeeding support. Barriers such as lack of time and trained staff in the maternity unit need to be addressed.

Maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals: An integrative review

Background

The Baby-Friendly Hospital Initiative aims to improve breastfeeding by implementing the Ten Steps to Successful Breastfeeding (Ten Steps) into routine breastfeeding support in birth hospitals. Maternal perspective to breastfeeding support is important to consider as mothers and their infants are in the center of that support.

Objectives

To review and synthesize the existing literature on maternal perceptions and experiences of breastfeeding support in Baby-Friendly hospitals. A sub-aim was to describe differences in breastfeeding support between Baby-Friendly hospitals and non-Baby-Friendly hospitals from maternal perspective.

Data sources and review methods

An integrative literature review. A systematic literature search was conducted in October 2021 in five databases: PubMed, CINAHL, Cochrane, Scopus, Web of Science. Original peer-reviewed studies published in English exploring maternal viewpoints on breastfeeding support in Baby-Friendly hospitals were included. Two reviewers independently screened the titles (n=914), abstracts (n=226), and full texts (n=47). The review comprised of seventeen studies and includes both quantitative studies (n=14) and qualitative studies (n=3). Inductive content analysis and descriptive synthesis were conducted.

Results

Most studies (n=14) measured hospitals' compliance with the Ten Steps practices from maternal perspective. Mothers were provided with breastfeeding information and encouragement, however, a qualitative finding indicated that information focused on positive aspects of breastfeeding. Early skin-to-skin contact between the mother and infant was well facilitated although often not lasting more than 30 min. Breastfeeding was facilitated by practical support but according to findings of two qualitative studies, support was not always adequate to address mothers' problems with breastfeeding. Most mothers were exclusively breastfeeding during the hospital stay and no supplemental milk was offered to infant. Mothers were roomed-in together with their infant and were mostly encouraged to breastfeed on demand. Differences between Baby-Friendly hospitals and non-Baby-Friendly hospitals were observed particularly for steps 6 and 9: supplementary feeding and pacifier use were less common in Baby-Friendly hospitals.

Conclusions

From the maternal perspective, breastfeeding support in the Baby-Friendly hospitals was mainly but not completely in adherence with the Ten Steps practices. Low compliance with some of the Ten Steps indicates a need for a more frequent assessment of the breastfeeding support practices and consideration of strategies facilitating a more sustainable implementation of the initiative. Regardless of some shortcomings with the breastfeeding support, mothers were mainly satisfied with the support in the hospital. Mothers in the Baby-Friendly hospitals perceived that breastfeeding support was more adherent to the Ten Steps compared to mothers in non-Baby-Friendly hospitals.

Experiences that influence how trained providers support women with breastfeeding: A systematic review of qualitative evidence

INTRODUCTION

There is a need to improve breastfeeding support interventions as although many are evidence-based, a sequential increase in breastfeeding rates is not evident. It is crucial to understand why the implementation of evidence-based guidelines in practice does not always translate to positive experiences for women and improve breastfeeding rates. This systematic review aims to synthesise breastfeeding support experiences of trained support providers and their impact on breastfeeding support practices.

METHODS

A strategy was developed to search seven databases including Medline and CINAHL and grey literature for qualitative studies. Studies eligible for inclusion reported professional and trained peer experiences of supporting women to breastfeed. PRISMA guidelines were followed and included studies were quality appraised using the CASP Qualitative Checklist. A thematic synthesis of included studies was undertaken and confidence in the review findings was assessed using the CERQual tool. The study protocol, registered in the International Prospective Register of Systematic Reviews PROSPERO registration number: CRD42020207380, has been peer reviewed and published.

FINDINGS

A total of 977 records were screened, which identified 18 studies (21 papers) eligible for inclusion comprising 368 participants. Following quality appraisal, all studies were deemed suitable for inclusion. The thematic synthesis resulted in four analytical themes: 1) A personal philosophy of breastfeeding support 2) Teamwork and tensions in practice 3) Negotiating organisational constraints and 4) Encounters with breastfeeding women. Findings demonstrated that a range of experiences influence practice, and practice evolves on continued exposure to such experiences. The potential of each experience to facilitate or inhibit breastfeeding support provision is fluid and context specific.

CONCLUSIONS

Experiences, as named above, are modifiable factors contributing to the development of a philosophy of breastfeeding support based on what the provider believes works and is valuable in practice. Further research is required into the range of factors which underpin context-specific breastfeeding support practice, to improve both women's experiences and intervention effectiveness.

Healthcare provider's experiences of supporting breastfeeding: protocol for a systematic review of qualitative evidence

INTRODUCTION

Breastfeeding provides various health benefits to both mothers and infants. Despite the efforts that have been made, breastfeeding rates remain lower than recommended worldwide. Healthcare providers often fail to provide the support women need due to various reasons such as lack of time and competency, discontinuity of care and so on. Synthesis of the primary qualitative studies exploring healthcare providers' experience with supporting breastfeeding can provide greater insights into their perceived barriers and facilitators and further provide evidence for the implementation of interventions to improve breastfeeding services.

METHODS AND ANALYSIS

Qualitative studies exploring healthcare providers' experiences with breastfeeding services will be searched in the following databases: PubMed, Embase, CINAHL, Scopus, ProQuest, PsycINFO, the Cochrane Library, Web of Science, China Biology Medicine disc, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, Chinese Wanfang Data, ProQuest Dissertations and Theses, Open Grey collection. Studies reported in English or Chinese and conducted between January 1990 to July 2021 will be included. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research will be used to assess the methodological quality of included studies. The JBI standardised data extraction tools will be used to extract data. The JBI meta-aggregation method will be used to synthesise the data. The synthesised findings will be graded finally according to the ConQual approach to establish confidence. Two authors will independently screen and select the search output, extract data, assess methodological quality and cluster findings. Any disagreements that arise between the two reviewers will be adjudicated by a third reviewer to reach a consensus.

ETHICS AND DISSEMINATION

This review will use published data, so it will not require ethical approval. The findings of this systematic review will be disseminated via an international peer-reviewed journal publication and several scientific conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021254542.

Barriers and facilitators to implementing practices for prevention of childhood obesity in primary care: A mixed methods systematic review

Primary care providers (PCPs) have an important role in prevention of excess weight gain in pre-school children. Guidelines exist to support PCPs' practices. This systematic review of PCPs' practice behaviors and their perceptions of barriers to and facilitators of implementation of guidelines was the first step toward the development of an intervention aimed at supporting PCPs. Five databases were searched to identify qualitative, quantitative, and mixed methods studies which examined PCPs' practice patterns and factors influencing implementation of recommended practices. The convergent integrated approach of the Joanna Briggs Institute (JBI) methodology for mixed methods reviews was used for data synthesis. Following analyses, the resultant factors were mapped onto the Capability, Opportunity, and Motivation model of Behaviour (COM-B). Fifty studies met the eligibility criteria. PCPs inconsistently implement recommended practices. Barriers and facilitators were identified at the provider (e.g., lack of knowledge), parent (e.g., lack motivation), and organization level (e.g., inadequate training). Factors were mapped to all three components of the COM-B model: psychological capability (e.g., lack of skills), reflective motivation (e.g., beliefs about guidelines), automatic motivation (e.g., discomfort), physical opportunity (e.g., time constraints), and social opportunity (e.g., stigma). These findings reflect the complexity of implementation of childhood obesity prevention practices.

Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Postpartum women's experiences of social and healthcare professional support during the COVID-19 pandemic: A recurrent cross-sectional thematic analysis

Problem

Disrupted access to social and healthcare professional support during the COVID-19 pandemic have had an adverse effect on maternal mental health.

Background

Motherhood is a key life transition which increases vulnerability to experience negative affect.

Aim

Explore UK women’s postnatal experiences of social and healthcare professional support during the COVID-19 pandemic.

Methods

Semi-structured interviews were conducted with 12 women, approximately 30 days after initial social distancing guidelines were imposed (T1), and a separate 12 women were interviewed approximately 30 days after the initial easing of social distancing restrictions (T2). Recurrent cross-sectional thematic analysis was conducted in NVivo 12.

Findings

T1 themes were, ‘Motherhood has been an isolating experience’ (exacerbated loneliness due to diminished support accessibility) and ‘Everything is under lock and key’ (confusion, alienation, and anxiety regarding disrupted face-to-face healthcare checks). T2 themes were, ‘Disrupted healthcare professional support’ (feeling burdensome, abandoned, and frustrated by virtual healthcare) and ‘Easing restrictions are bittersweet’ (conflict between enhanced emotional wellbeing, and sadness regarding lost postnatal time).

Discussion

Respondents at both timepoints were adversely affected by restricted access to informal (family and friends) and formal (healthcare professional) support, which were not sufficiently bridged virtually. Additionally, the prospect of attending face-to-face appointments was anxiety-provoking and perceived as being contradictory to social distancing guidance. Prohibition of family from maternity wards was also salient and distressing for T2, but not T1 respondents.

Conclusion

Healthcare professionals should encourage maternal help-seeking and provide timely access to mental health services. Improving access to informal and formal face-to-face support are essential in protecting maternal and infant wellbeing.

Exploring the value and acceptability of an antenatal and postnatal midwifery continuity of care model to women and midwives, using the Quality Maternal Newborn Care Framework

BACKGROUND

Having a known midwife throughout pregnancy, birth and the early parenting period improves outcomes for mothers and babies. In Australia, midwifery continuity of care has been recommended in all states, territories and nationally although uptake has been slow. Several barriers exist to implementing midwifery continuity of care models and some maternity services have responded by introducing modified models of continuity of care. An antenatal and postnatal continuity of care model without intrapartum care is one example of a modified model of care that has been introduced by health services.

OBJECTIVES

The aim of this study was to explore the value and acceptability of an antenatal and postnatal midwifery program to women, midwives and obstetricians prior to implementation of the model at one hospital in Metropolitan Sydney, Australia.

METHODS

A qualitative descriptive methodology was undertaken to discover the value and acceptability to the implementation of the model. Data was collected via focus groups and one to one interviews from the service users (pregnant women and two partners) and service providers (midwives and obstetricians). We also collected demographic data to demonstrate the diversity of the setting. The Quality Maternal Newborn Care (QMNC) Framework was used to guide the focus groups and analyse the data.

FINDINGS

Four themes emerged from the data that were named feeling safe and connected, having more quality time and being confident, having a sense of community and respecting cultural diversity. The findings were analysed through the lens of the quality components of the QMNC framework. The final findings demonstrate the value and acceptability of implementing this model of care from women's, midwives and obstetrician's perspective.

CONCLUSIONS/IMPLICATIONS

Providing midwifery continuity of care through the antenatal and postnatal period without intrapartum care, is being implemented in Australia without any research. Using the QMNC framework is a useful way to explore the qualities of a new emerging service and the values and acceptability of this model of care for service providers and service users.

Integrative Review of the Experiences of Registered Nurses Who Support Breastfeeding Women

OBJECTIVE

To describe the experiences of registered nurses (RNs) who support breastfeeding women and to understand the factors that they believe affect practices that support breastfeeding.

DATA SOURCES

We conducted an online search using five databases: Scopus, MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Database of Systematic Reviews, and Joanna Briggs Institute of Systematic Reviews.

STUDY SELECTION

We included original research articles on the experiences of RNs who support breastfeeding women that were published in 2009 or after and were available in English. After title and abstract review of 785 articles, we included 22 articles for full text review. Nine articles met the eligibility criteria and were included in the review.

DATA EXTRACTION

We used Whittemore and Knafl's five-step framework and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines to guide this integrative review. Three authors reviewed and appraised the articles independently.

DATA SYNTHESIS

We categorized the findings into three themes: Workplace Issues, Personal Experiences, and Breastfeeding Knowledge and Education. Workplace Issues included the subthemes Lack of Time and Workload and Infant Health Stability. Personal Experiences included the subthemes Attitudes, Individual Experiences With Breastfeeding, and The Experiences of Family and Friends. Breastfeeding Knowledge and Education included the subthemes Prelicensure Education and Workplace Education and Training. Most researchers identified deficits in knowledge and education among RNs. The concept of confidence was influenced by all the other themes. Participants in the included studies reported that they developed confidence after learning from lactation consultants and having role models who supported the development of their knowledge and skills.

CONCLUSION

Despite the heterogeneity among the studies, findings highlighted the need for an increased focus on the preparation of RNs to support women to effectively breastfeed within health care organizations. Multitargeted efforts, such as orientation programs and in-depth breastfeeding education using role modeling, mentorship, and role playing with practical scenarios, may improve RNs' abilities and confidence to support breastfeeding women.

Guilt, shame, and postpartum infant feeding outcomes: A systematic review

Negative maternal affect (e.g., depression and anxiety) has been associated with shorter breastfeeding duration and poorer breastfeeding intention, initiation, and exclusivity. Other affective states, including guilt and shame, have been linked with formula feeding practice, though existing literature has yet to be synthesised. A narrative synthesis of quantitative data and a framework synthesis of qualitative and quantitative data were conducted to explore guilt and/or shame in relation to infant feeding outcomes. Searches were conducted on the DISCOVER database between December 2017 and March 2018. The search strategy was rerun in February 2020, together yielding 467 studies. The study selection process identified 20 articles, published between 1997 and 2017. Quantitative results demonstrated formula feeders experienced guilt more commonly than breastfeeding mothers. Formula feeders experienced external guilt most commonly associated with healthcare professionals, whereas breastfeeding mothers experienced guilt most commonly associated with peers and family. No quantitative literature examined shame in relation to infant feeding outcomes, warranting future research. The framework synthesis generated four distinct themes which explored guilt and/or shame in relation to infant feeding outcomes: 'underprepared and ineffectively supported', 'morality and perceived judgement' (breastfeeding), 'frustration with infant feeding care' and 'failures, fears and forbidden practice' (formula feeding). Both guilt and shame were associated with self-perception as a bad mother and poorer maternal mental health. Guilt and shame experiences were qualitatively different in terms of sources and outcomes, dependent on infant feeding method. Suggestions for tailored care to minimise guilt and shame, while supporting breastfeeding, are provided.

Women's successful transition to motherhood during the early postnatal period: A qualitative systematic review of postnatal and midwifery home care literature

OBJECTIVE

To undertake a systematic review of available qualitative research literature to determine what women need to successfully transition to motherhood during the early postnatal period and whether postnatal home care delivered by midwives supports this process.

DESIGN

The transition from woman to mother is a significant occurrence, one that requires adjustments on physical, psychological and social levels. A qualitative systematic review design was chosen to ensure both humanistic and interactive concepts related to what women need to successfully transition to motherhood during the early postnatal period were identified. The systematic and structured search uncovered 33 research articles for detailed review. Two team members, using the qualitative research checklist from the Critical Appraisal Skills Programme, appraised the quality of the research articles. A total of 19 articles met the quality criteria and were included in the data evaluation process.

SETTING AND PARTICIPANTS

Research teams from Asia-Pacific, Europe, Middle East and North America generated the 19 qualitative journal articles.

MEASUREMENTS AND FINDINGS

Data evaluation included identification of research aim, presence of a research question, type of methodology, data collection processes, sample information, data analysis techniques and study outcomes. Data was analysed using an inductive content analysis approach. Four themes were identified from the qualitative systematic review process including: women and midwives connecting, identification and meeting of women's individual needs, family and cultural influences and, education and support.

KEY CONCLUSIONS

The ability of women to connect with midwives during the early postnatal period assisted them overcome barriers and to successfully transitioning to motherhood. Although all four themes were determined to be key to effective postnatal transition, overwhelmingly the findings showed postnatal midwifery home care to be important in women's successful transition to motherhood in the early postnatal period.

IMPLICATIONS FOR PRACTICE

Strategies are needed ensure women have access to midwives in the early postnatal period.

Breastfeeding as a public health responsibility: a review of the evidence

BACKGROUND

Although intention to breastfeed in Western culture is high, many women stop breastfeeding before they are ready. From a physiological perspective, rates of primary milk insufficiency or contraindications to breastfeed should be low. However, numerous women encounter numerous barriers to breastfeeding, many of which occur at the social, cultural and political level and are therefore outside of maternal control. This review identifies and examines the impact of these barriers and considers how public health services should play a central role in creating a supportive breastfeeding environment.

METHODS

A narrative review to synthesise themes in the literature was conducted, using Web of Science, PubMed and Science Direct. Barriers to breastfeeding at the societal rather than individual level were identified (e.g. in relation to health services, policies and economic factors). Only English language papers were included.

RESULTS

Many barriers to breastfeeding exist at the societal rather than individual level. These influences are typically outside mothers' control. Five core themes were identified; the need for investment in (i) health services; (ii) population level health promotion; (iii) supporting maternal legal rights; (iv) protection of maternal wellbeing; and (v) reducing the reach of the breast milk substitute industry.

CONCLUSIONS

Although individual support is important, breastfeeding must be considered a public health issue that requires investment at a societal level. Focusing solely on solving individual issues will not lead to the cultural changes needed to normalise breastfeeding. Countries that have adopted a multicomponent public heath strategy to increase breastfeeding levels have had significant success. These strategies must be emulated more widely.

"The right help at the right time": Positive constructions of peer and professional support for breastfeeding

Problem or issue

Support during the early establishment phase of breastfeeding is important but women report that health professionals can undermine their confidence with breastfeeding.

What is already known

Breastfeeding support provided in fragmented hospital based models of care predominantly reflect authoritative expert advice-giving which women describe as conflicting and unsupportive. Women show a preference for support from a known midwife, or a peer supporter, or a combination of the two.

What this paper adds

Peer support counsellors and privately practicing midwives approached breastfeeding support in a similar way. They interacted with women as a ‘knowledgeable friend’ and normalised breastfeeding challenges which enhanced women’s confidence with breastfeeding.

Supporting breast-feeding women from the perspective of the midwife: A systematic review of the literature

INTRODUCTION

In 2003 the World Health Organization (WHO) recommended that infants should be fed exclusively with breast milk until the age of six months. However, breast feeding rates remain lower than recommended. The crucial period for breast feeding support is the first two weeks after birth. During this period breast feeding support from the midwife is needed. The aim of this paper is to gain an in-depth understanding of the role of midwives in their support of breast-feeding women, from their own perspective.

METHODS

Two researchers independently conducted a systematic and comprehensive literature search. Studies needed an empirical qualitative research design (1), had to focus on the role of the midwife in the support of the breast-feeding woman from the midwife's perspective (2), and had to be published between January 2005 and December 2014 (3) in order to be included. Language restrictions were English, Dutch, German and French. Eight qualitative research studies were included, using mainly focus group and in-depth interview studies, which were reported in 11 papers representing 231 midwives and 24 maternity nurses. All but one study concerned midwives working in hospital settings. A critical appraisal was performed of each study.

FINDINGS

Midwives value breast feeding education and breast feeding support as a significant part of their role as a postnatal midwife. However, the ways in which a midwife approaches and supports the breast-feeding woman vary. We distinguished two perspectives: 'the midwife as technical expert' and 'the midwife as a skilled companion'. The 'technical expert' midwife is mainly breast centred, focuses on techniques, uses the hands on approach and sees a woman as a novice. The 'skilled companion' midwife is woman centred, focuses on the mother - infant relationship and uses a hands off approach during the breast feeding support. The midwives working in a hospital setting face many barriers when performing breast feeding support, such as time restraints, which makes it difficult for them to carry out their preferred role as a 'skilled companion'. These barriers can influence the breast feeding support negatively. Supporting factors, such as evidence based breast feeding guidelines, have a positive influence on the breast feeding support.

CONCLUSION

On the basis of findings of a synthesis of qualitative research studies, we conclude that the majority of the midwives provide breast feeding support as a technical expert and a minority as a skilled companion. Midwives prefer to be a skilled companion but face many barriers in their working contexts.