The effect of health visitors on breastfeeding in Glasgow

Emotional and informational social support from health visitors and breastfeeding outcomes in the UK

BACKGROUND

Shorter breastfeeding duration is associated with detrimental consequences for infant health/development and maternal health. Previous studies suggest social support is essential in maintaining breast/chest-feeding and helping to improve general infant feeding experiences. Public health bodies therefore work to support breastfeeding in the UK, yet UK breastfeeding rates continue to be one of the lowest globally. With this, a better understanding of the effectiveness and quality of infant feeding support is required. In the UK, health visitors (community public health nurses specialising in working with families with a child aged 0-5 years) have been positioned as one of the key providers of breast/chest-feeding support. Research evidence suggests that both inadequate informational support and poor/negative emotional support can lead to poor breastfeeding experiences and early breastfeeding cessation. Thus, this study tests the hypothesis that emotional support from health visitors moderates the relationship between informational support and breastfeeding duration/infant feeding experience among UK mothers.

METHODS

We ran cox and binary logistic regression models on data from 565 UK mothers, collected as part of a 2017-2018 retrospective online survey on social support and infant feeding.

RESULTS

Informational support, compared to emotional support, was a less important predictor of both breastfeeding duration and experience. Supportive emotional support with unhelpful or absent informational support was associated with the lowest hazard of breastfeeding cessation before 3 months. Results for breastfeeding experience followed similar trends, where positive experience was associated with supportive emotional and unhelpful informational support. Negative experiences were less consistent; however, a higher probability of negative experience was found when both types of support were reported as unsupportive.

CONCLUSIONS

Our findings point to the importance of health visitors providing emotional support to bolster the continuation of breastfeeding and encourage a positive subjective experience of infant feeding. The emphasis of emotional support in our results encourages increased allocation of resources and training opportunities to ensure health visitors are able to provide enhanced emotional support. Lowering health visitors caseloads to allow for personalised care is just one actionable example that may improve breastfeeding outcomes in the UK.

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.

The effect of nursing interventions on immigrant women living in Northern Cyprus on their breastfeeding self-efficacy and success: a randomized controlled trial

This study was conducted as a randomized controlled study to determine the effect of nursing interventions, which were based on Dennis's Breastfeeding Self-Efficacy Theory and Pender's Health Promotion Model during home visits, on the breastfeeding self-efficacy and success of immigrant women living in Northern Cyprus. The sample consisted of N = 60 primipar immigrant women (experimental group n = 30, control group n = 30) who attended a primary healthcare center in Northern Cyprus between April 2019 and January 2020. The data were collected from the participants using a Socio-Demographic Questionnaire, the Breastfeeding Self-Efficacy Scale and the LATCH Breastfeeding Assessment Tool. Before the study, no statistically significant difference was found between two groups in terms of breastfeeding self-efficacy and the LATCH assessment (p > 0.05). After the intervention, the mean score for the Breastfeeding Self-Efficacy Scale increased by 9.73 in the experimental group and 3.16 in the control group compared to before the study, and the effect size was found to be 6.57. The score for the LATCH assessment increased by 3.2 in the experimental group and 1.44 in the control group, and the effect size was found to be 1.76 (p < 0.05).

Knowledge and attitudes towards breastfeeding practices: A cross-sectional survey of postnatal mothers in China

OBJECTIVE

To examine the mothers' knowledge and attitudes toward breastfeeding and highlight barriers to exclusive breastfeeding in Chinese postpartum mothers.

DESIGN

Cross sectional survey SETTING: Maternity wards of two large, multi-service teaching hospitals, Wuhan, China.

PARTICIPANTS

324 postnatal mothers completed a structured questionnaire during their stay at hospital from October 2016 to January 2017.

MEASUREMENTS AND FINDINGS

Descriptive and inferential statistics revealed that most mothers showed neutral attitude on breastfeeding and neutral knowledge level as well. The average score for the total Iowa Infant Feeding Attitude Scale (IIFAS) was 56.55±4.77 M±SD, and 10.83±2.77, M±SD for the knowledge section. The mothers who had poor knowledge were less likely to initiate breastfeeding within an hour after birth.

CONCLUSIONS

The results of this study are applicable to nurses and nurse midwives to assist in identification of women who may be at-risk to not initiate breastfeeding. Maternal positive attitude and good knowledge play key roles in the process of breastfeeding. Thus, it is important to provide antenatal and early postpartum education and periodical breastfeeding counselling, especially for new mothers, to improve maternal attitudes and knowledge toward breastfeeding practices.

The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed-methods systematic review

Global evidence demonstrates that adherence to the Baby Friendly Initiative (BFI) has a positive impact on multiple child health outcomes, including breastfeeding initiation and duration up to 1 year post-partum. However, it is currently unclear whether these findings extend to specific countries with resource-rich environments. This mixed-methods systematic review aims to (a) examine the impact of BFI implementation (hospital and community) on maternal and infant health outcomes in the United Kingdom (UK) and (b) explore the experiences and views of women receiving BFI-compliant care in the UK. Two authors independently extracted data including study design, participants, and results. There is no UK data available relating to wider maternal or infant health outcomes. Two quantitative studies indicate that Baby Friendly Hospital Initiative implementation has a positive impact on breastfeeding outcomes up to 1 week post-partum but this is not sustained. There was also some evidence for the positive impact of individual steps of Baby Friendly Community Initiative (n = 3) on breastfeeding up to 8 weeks post-partum. Future work is needed to confirm whether BFI (hospital and community) is effective in supporting longer term breastfeeding and wider maternal and infant health outcomes in the UK. A meta-synthesis of five qualitative studies found that support from health professionals is highly influential to women's experiences of BFI-compliant care, but current delivery of BFI may promote unrealistic expectations of breastfeeding, not meet women's individual needs, and foster negative emotional experiences. These findings reinforce conclusions that the current approach to BFI needs to be situationally modified in resource-rich settings.

Infant Feeding Attitudes and Practices of Spanish Low-Risk Expectant Women Using the IIFAS (Iowa Infant Feeding Attitude Scale)

The Iowa Infant Feeding Attitude Scale (IIFAS) has been shown to have good psychometric properties for English-speaking populations, but it has not been validated among low-risk pregnant women in Spain. The aim of this study was to assess the reliability and validity of the translated version of the IIFAS in order to examine infant feeding attitudes in Spanish women with an uncomplicated pregnancy. Low-risk expectant women (n = 297) were recruited from eight primary public health care centres in Galicia (Spain). Questionnaires including both socio-demographic and breastfeeding characteristics and items about infant feeding were administered during the third trimester. Participants were contacted by telephone during the postpartum period to obtain information regarding their infant feeding status. Prediction validity and internal consistency were assessed. The translated IIFAS (69.76 ± 7.75), which had good psychometric properties (Cronbach's alpha = 0.785; area under the curve (AUC) of the receiver operating characteristic (ROC) curve = 0.841, CI95% = 0.735⁻0.948), showed more positive attitudes towards breastfeeding than towards formula feeding, especially among mothers who intended to exclusively breastfeed. This scale was also useful for inferring the intent to breastfeed and duration of breastfeeding. This study provides evidence that the IIFAS is a reliable and valid tool for assessing infant feeding attitudes in Spanish women with an uncomplicated pregnancy.

Health visitor education for today's Britain: Messages from a narrative review of the health visitor literature

OBJECTIVES

This paper draws on a narrative review of the literature, commissioned to support the Health Visitor Implementation Plan, and aimed at identifying messages about the knowledge, skills, and abilities needed by health visitors to work within the current system of health care provision.

DESIGN

The scoping study and narrative review used three complementary approaches: a broad search, a structured search, and a seminal paper search to identify empirical papers from the health visitor literature for review. The key inclusion criteria were messages of relevance for practice.

DATA SOURCES

378 papers were reviewed. These included empirical papers from the United Kingdom (UK) from 2004 to February 2012, older research identified in the seminal paper search and international literature from 2000 to January 2016.

REVIEW METHODS

The review papers were read by members of the multidisciplinary research team which included health visitor academics, social scientists, and a clinical psychologist managed the international literature. Thematic content analysis was used to identify main messages. These were tabulated and shared between researchers in order to compare emergent findings and to confirm dominant themes.

RESULTS

The analysis identified an 'orientation to practice' based on salutogenesis (health creation), human valuing (person-centred care), and viewing the person in situation (human ecology) as the aspirational core of health visitors' work. This was realised through home visiting, needs assessment, and relationship formation at different levels of service provision. A wide range of knowledge, skills, and abilities were required, including knowledge of health as a process and skills in engagement, building trust, and making professional judgments. These are currently difficult to impart within a 45week health visitor programme and are facilitated through ad hoc post-registration education and training. The international literature reported both similarities and differences between the working practices of health visitors in the UK and public health nurses worldwide. Challenges related to the education of each were identified.

CONCLUSIONS

The breadth and scope of knowledge, skills, and abilities required by health visitors make a review of current educational provision desirable. Three potential models for health visitor education are described.

Assessing Infant Feeding Attitudes of Expectant Women in a Provincial Population in Canada: Validation of the Iowa Infant Feeding Attitude Scale

BACKGROUND

Maternal attitudes to infant feeding are predictive of intent and initiation of breastfeeding.

OBJECTIVES

The Iowa Infant Feeding Attitude Scale (IIFAS) has not been validated in the Canadian population. This study was conducted in Newfoundland and Labrador, a Canadian province with low breastfeeding rates. Objectives were to assess the reliability and validity of the IIFAS in expectant mothers; to compare attitudes to infant feeding in urban and rural areas; and to examine whether attitudes are associated with intent to breastfeed.

METHODS

The IIFAS assessment tool was administered to 793 pregnant women. Differences in the total IIFAS scores were compared between urban and rural areas. Reliability and validity analysis was conducted on the IIFAS. The receiver operating characteristic (ROC) of the IIFAS was assessed against mother's intent to breastfeed.

RESULTS

The mean ± SD of the total IIFAS score of the overall sample was 64.0 ± 10.4. There were no significant differences in attitudes between urban (63.9 ± 10.5) and rural (64.4 ± 9.9) populations. There were significant differences in total IIFAS scores between women who intend to breastfeed (67.3 ± 8.3) and those who do not (51.6 ± 7.7), regardless of population region. The high value of the area under the curve (AUC) of the ROC (AUC = 0.92) demonstrates excellent ability of the IIFAS to predict intent to breastfeed. The internal consistency of the IIFAS was strong, with a Cronbach's alpha greater than .80 in the overall sample.

CONCLUSION

The IIFAS examined in this provincial population provides a valid and reliable assessment of maternal attitudes toward infant feeding. This tool could be used to identify mothers less likely to breastfeed and to inform health promotion programs.

Breastfeeding attitudes: association between maternal and male partner attitudes and breastfeeding intent

Breastfeeding is considered the best infant feeding method, yet initiation and duration rates in the United States are lower than recommended by medical and public health professionals. Positive attitudes toward breastfeeding of the male partner are important in a mother's success at initiating and maintaining breastfeeding. This study measured the infant feeding attitudes of low-income women and their male partners using the Iowa Infant Feeding Attitude Scale (IIFAS), investigated the reliability and validity of the measure in male partners, and examined the associations of the partner's attitudes with the mother's attitudes and intention to breastfeed. A convenience sample of 112 pregnant women and their male partners completed a survey including sociodemographic items, the IIFAS, and their intended infant feeding method in the hospital and in the first few weeks after the infant's birth (breastfeeding, formula feeding, mixed, and don't know). Mother's and partner's IIFAS scores were highly correlated, and higher scores of both mothers and partners were significantly associated with their intentions to breastfeed. With each increased point on mother's and partner's IIFAS scores, the odds that the mother and her partner intended to breastfeed in the first few weeks increased 12% and 20%, respectively. This is the first U.S. study to validate the IIFAS with male partners. Future research on breastfeeding attitudes and attitude-changing interventions is needed to see if improving partners' attitudes toward breastfeeding will also improve mothers' attitudes and if that increases initiation and duration of breastfeeding.

Maternal sociodemographic characteristics and the use of the Iowa Infant Attitude Feeding Scale to describe breastfeeding initiation and duration in a population of urban, Latina mothers: a prospective cohort study

BACKGROUND

The World Health Organization recommends exclusive breastfeeding until 6 months of age. Maternal attitudes toward infant feeding are correlated with chosen feeding method and breastfeeding duration. The Iowa Infant Feeding Attitude Scale (IIFAS) has been used to assess attitudes towards breastfeeding prenatally and is predictive of breastfeeding decisions in certain population groups.

METHODS

In a cohort of pregnant Latina women recruited from two hospitals in the San Francisco Bay Area (n=185), we administered the IIFAS prior to delivery. Information regarding feeding choice, maternal sociodemographic information, and anthropometrics were collected at 6 months and 1 year postpartum. Analysis of predictors for breastfeeding initiation, breastfeeding at 6 and 12 months and exclusive breastfeeding at 6 months were evaluated using multivariate logistic regression adjusting for potential confounders.

RESULTS

In our cohort of Latina mothers, breastfeeding a previous infant was associated with breastfeeding initiation (OR 8.29 [95% CI 1.00, 68.40] p = 0.05) and breastfeeding at 6 months (OR 18.34 [95% CI 2.01, 167.24] p = 0.01). College education was associated with increased exclusive breastfeeding at 6 months (OR 58.67 [95% CI 4.97, 692.08] p = 0.001) and having other children was associated with reduced breastfeeding at six months (OR 0.08 [95% CI 0.01, 0.70] p = 0.02). A higher IIFAS score was not associated with breastfeeding initiation, breastfeeding at 6 or 12 months or exclusive breastfeeding at 6 months of age.

CONCLUSIONS

Initial choices about breastfeeding will likely influence future breastfeeding decisions, so breastfeeding interventions should specifically target new mothers. Mothers with other children also need additional encouragement to maintain breastfeeding until 6 months of age. The IIFAS, while predictive of breastfeeding decisions in other population groups, was not associated with feeding decisions in our population of Latina mothers.

Factors influencing initiation and duration of breast feeding in Ireland

The aim of this research was to identify factors associated with mothers breast feeding and to identify, for those who breast fed, factors associated with breast feeding for as long as planned.

BACKGROUND

breast feeding rates in Ireland are amongst the lowest in Europe. Research evidence indicates that in order for mothers to be successful at breast feeding, multiplicities of supports are necessary for both initiation and duration. The nature of these supports in tandem with other influencing factors requires analysis from an Irish perspective.

DESIGN

cross-sectional study involving public health nurses and mothers in Ireland. This paper presents the results of the mothers' evaluation.

METHOD

mothers (n=1715) with children less than three years were offered a choice of completing the self-report questionnaires online or by mail. Data were analysed and reported using descriptive and inferential statistics.

FINDINGS

four in every five participants breast fed their infant and two thirds of them breast fed as long as planned. The multivariate logistic regression analysis identified that third level education, being a first time mother or previously having breast fed, participating online, having more than two public health nurse visits, and having a positive infant feeding attitude were independently and statistically significantly associated with breast feeding. Among mothers who breast fed, being aged at least 35 years, participating online, having a positive infant feeding attitude and high breast feeding self-efficacy were independently and statistically significantly associated with breast feeding for as long as planned.

CONCLUSIONS

findings from this study reinforce health inequalities therefore there needs to be a renewed commitment to reducing health inequalities in relation to breast feeding.

RELEVANCE TO CLINICAL PRACTICE

this study has identified factors associated with initiation and duration of breast feeding that are potentially modifiable through public health interventions.

Predicting breastfeeding duration related to maternal attitudes in a taiwanese sample

The purpose of this study was to examine maternal attitudes and sociodemographic variables associated with Taiwanese mothers' continuation of breastfeeding at 6 weeks postpartum. A sample of 140 in-hospital breastfeeding mothers was recruited in Taiwan. Participants completed the Iowa Infant Feeding Attitude Scale (IIFAS) in the hospital prior to discharge. Postdischarge participants were contacted by telephone at 3 and 6 weeks postpartum to obtain information regarding their feeding method and duration. Findings revealed that in-hospital maternal breastfeeding attitudes are predictive of breastfeeding duration. Insufficient milk supply was the reason most often given for discontinuing breastfeeding. Women's husband/partner was found to be the main source of breastfeeding support. We recommend health-care professionals add the IIFAS to their assessment to identify mothers at high risk for discontinuing breastfeeding and to develop and better evaluate breastfeeding promotion programs.

The effect of early postpartum home visits by health visitors: a natural experiment

OBJECTIVE

The purpose of this study was to assess if the absence of early home visits influenced the mothers' breastfeeding duration and use of medical services.

DESIGN

Data from mothers who had given birth during a strike period were compared with data from a reference period with usual work practice.

SAMPLE

The study included 3,834 newborn and 375 health visitors, 75 of whom worked during the strike period.

INTERVENTION

All families were offered nonstandardized home visits after discharge in the reference period. During the strike, the service was based on individual risk assessment.

RESULTS

Overall, no difference in breastfeeding duration between the two periods was seen, but unvisited mothers in the strike period had shorter durations of full breastfeeding than a comparable group of mothers in the reference period (p < .005). Moreover, mothers in the strike period reported a significantly higher use of medical services. The mothers' needs for postnatal visits differed depending on parity: primiparae underlined uncertainty, multiparae underlined previous breastfeeding experience. Mothers had missed out on guidance on all areas of the health visitors' service.

CONCLUSION

Nonstandardized home visits by health visitors were associated with a longer breastfeeding duration. The postnatal visits depended on parity and unmet needs increased the use of medical services.

Effectiveness of the UNICEF/WHO 20-hour course in improving health professionals' knowledge, practices, and attitudes to breastfeeding: before/after study of 5 maternity facilities in Croatia

AIM

To evaluate knowledge, practices, and attitudes to breastfeeding among Croatian health professionals before and after the United Nations International Children's Emergency Fund/World Health Organization (UNICEF/WHO) 20-hour course.

METHODS

Study included 5 of 9 maternity hospitals in southern Croatia, which had completed the UNICEF/WHO 20-hour breastfeeding training course between December 2007 and February 2009. An anonymous questionnaire testing knowledge and practices, and attitudes was distributed to 424 health professionals before training and to 308 health professionals afterwards. Health professionals' attitudes were assessed using the validated Iowa Infant Feeding Attitude Scale.

RESULTS

The pre-training response rate was >90%, but only 53% of data were analyzed; the post-training response rate was 69%. Only one-fifth of health professionals prior to training knew that breast preparation in pregnancy was unnecessary, but this increased to 57% after training (P<0.001). The proportion of health professionals who recognized hospital practices that support breastfeeding and signs of poor positioning when breastfeeding nearly doubled after training (P<0.001). The proportion of health professionals correctly recommending immediate "skin-to-skin" contact post-Cesarean section under local anesthesia did not improve significantly, and stratification analyses showed that younger respondents (<36 years) were more likely to support this practice. Although the proportion of health professionals who correctly managed mastitis improved significantly as a result of the training, the proportion of those who after training inappropriately recommended partial or complete cessation of breastfeeding remained high at 47%. The number of staff with positive attitudes toward breastfeeding increased from 65% to 79%, whereas the number of staff with neutral attitudes dropped from 26.6% to 9.9% (P<0.001). Even after training, a substantial proportion of health professionals showed uncertainty in their attitude toward alcohol consumption and breastfeeding.

CONCLUSION

The UNICEF/WHO 20-hour course appears to be an effective tool for improving health professionals' breastfeeding knowledge, attitudes, and practices.

Reliability and validity of the Romanian version of a scale to measure infant feeding attitudes and knowledge

AIM

To describe the development and testing of the Romanian version of the Iowa Infant Feeding Attitude Scale (IIFAS-R). The original instrument has well-established psychometrics for use in English-speaking countries.

METHODS

Questionnaires including demographics and items about prior pregnancy and opinions about breastfeeding in public were administered to women in Cluj-Napoca, Romania, attending antenatal clinic (n = 336) and to a separate cohort of mothers within 24 h of delivery (n = 276). Postpartum follow-up was conducted with a sample of maternity cohort subjects who initiated breastfeeding in the hospital (n = 52).

RESULTS

Internal consistency was adequate in both cohorts (antenatal alpha= 0.50; maternity alpha= 0.63), with improved reliability for antenatal multigravid (alpha= 0.60) and university-educated women (alpha= 0.57). Score distributions were comparable and item means were approximately central across cohorts. Among pregnant women, higher scores (more positive towards breastfeeding) were associated with longer planned maternity leave (chi2= 17.8; p = 0.02). Higher maternity cohort scores were associated with age (r = 0.31, p = 0.003), urban residence (chi2= 10.2, p = 0.04), breastfeeding a prior infant for at least 6 weeks (chi2= 6.4, p = 0.04), and with intending to breastfeed for at least 6 weeks (chi2= 4.7, p = 0.03). Postpartum women still breastfeeding at follow-up also scored higher (chi2= 9.3, p = 0.009).

CONCLUSION

This is the first study to report on use of the IIFAS in Eastern Europe. The IIFAS-R is easy to administer, reliable and valid in Romania. The IIFAS-R can support data collection to promote and assess breastfeeding initiatives consistent with World Health Organization recommendations.

Infant feeding attitudes and knowledge among socioeconomically disadvantaged women in Glasgow

OBJECTIVES

This study: (1) investigated infant feeding attitudes and knowledge among socioeconomically disadvantaged mothers in an urban community with historically low breastfeeding rates, (2) examined the influence of women's social networks on infant feeding attitudes and decisions, and (3) validated a measure of infant feeding attitudes and knowledge in this population (Iowa Infant Feeding Attitude Scale, IIFAS).

METHODS

Women attending a prenatal clinic (n=49) reported on: (1) demographics, (2) infant feeding attitudes and knowledge (IIFAS), (3) feeding intent, (4) opinions about breastfeeding in public, and (5) social networks. Feeding method at discharge was abstracted from hospital charts. Social network members (n=47) identified by the prenatal sample completed interviews covering: (1) demographics, (2) infant feeding attitudes and knowledge (IIFAS), (3) prior infant feeding methods and recommendations, and (4) opinions about breastfeeding in public.

RESULTS

Mean IIFAS scores were low in both groups, indicating neutral to negative breastfeeding attitudes; mothers' scores were lower than social network members. Higher maternal IIFAS score was significantly associated with intended and actual breastfeeding. A social network positive towards breastfeeding was significantly associated with mothers' positive attitude towards breastfeeding. Both mothers and social network members support breastfeeding in public. IIFAS internal consistency was robust for both mothers and social network members. Predictive validity was demonstrated by significant positive association between score and intended and actual feeding methods.

CONCLUSIONS

Knowledge and attitude predict breastfeeding initiation in this population. Social network members may influence mothers' feeding choices. This research is important because attitudes and knowledge derived from the IIFAS can be used to develop and evaluate breastfeeding promotion programs.

Feeding by numbers: an ethnographic study of how breastfeeding women understand their babies' weight charts

BACKGROUND

Weighing breastfed babies has been the subject of some controversy as the previous international growth chart was largely based on data from infants fed infant formula. The concern that professionals may be misled by the charts into suggesting to mothers that they supplement unnecessarily was a major impetus for the World Health Organization's investment in a new growth chart. Evidence of interpretation in practice has been scant.

METHODS

An ethnographic study was conducted in a town in the Northwest of England to investigate this issue. In the first phase, women and health visitors were observed in the well-child clinic during clinic sessions and breastfeeding group meetings. In the second phase, longitudinal interviews with 14 women were conducted. Each woman was interviewed up to three times in the first six months after the birth of her baby, with a total of 35 interviews.

RESULTS

Mothers and health visitors focussed on weight gain with frequent weighing and attention to even minor fluctuations of the plotted line being evident. Women felt it important to ensure their baby's weight followed a centile, and preferred for this to be the fiftieth centile. Interventions included giving infant formula and solids as well as changing what the mother ate and drank. Women also described how they worried about their baby's weight. Little effective support by health professionals with breastfeeding technique was observed.

CONCLUSION

Babies were weighed more often than officially recommended, with weighing and plotting being at the core of each clinic visit. The plotted weight chart exerted a powerful influence on both women's and health visitors' understanding of the adequacy of breastfeeding. They appeared to rate the regular progression of weight gains along the chart centiles more highly than continued or exclusive breastfeeding. Thus weighing and visual charting of weight constituted a form of surveillance under the medical gaze, with mothers actively participating in self monitoring of their babies. Interventions, by mothers and health visitors, were targeted towards increasing weight gain rather than improving breastfeeding effectiveness. Improvements in training are needed for health visitors in weighing techniques, assessing growth patterns--particularly of breastfed babies--and in giving information to women, if the practice of routine weight monitoring is to support rather than undermine breastfeeding.