Confidence in Initiation of Breastfeeding

Background: Breastfeeding confers health and social benefits on both mother and baby and is thus a key global public health priority, with exclusive breastfeeding for the first six months recommended. A variety of factors can influence a woman’s decision to initiate breastfeeding but a short duration of breastfeeding appears to be common in developed countries. In the UK, promotion of breastfeeding has been government policy since 1974 and gradually the incidence has increased. In Scotland in 2010 the incidence was 74% but by one week 17% of women had given up. A minority of women find that their babies attach easily at birth and more than half report problems at this time. The prevalence of exclusive breastfeeding falls sharply in the first few weeks and the introduction of formula is associated with a shorter duration. It is therefore crucial to understand what happens at this time to enable women to continue breastfeeding effectively. Study Aim: To use Social Cognitive Theory (SCT) to explore and help explain the expectations, knowledge and experiences of women and midwives with regard to breastfeeding initiation. Methods: A systematic review of qualitative studies synthesised using thematic analysis and SCT was conducted and afforded insight into what had been known before and highlighted further aspects that needed to be explored with a qualitative study. The qualitative study was comprised of five focus groups with ten antenatal women, eight postnatal women and eighteen midwives. Photographs included in a leaflet “Feeding cues at birth”, and the chart of “Feeding cues after the first few hours” were developed and used as focussing exercises during the focus groups and interviews. The focus groups and interviews were recorded, transcribed and analysed using a hybrid process of inductive and deductive thematic analysis which integrated data driven codes with theory driven codes based on SCT. Results: Twenty one studies were included in the systematic review and identified clear differences in the experiences of women when breastfeeding was going well as compared to when it was going wrong at the start. There were also differences in the midwives’ knowledge, experience and confidence when breastfeeding was going well in contrast to when it was going wrong. The synthesis did not identify any qualitative studies relevant to initiation which explored skin contact, instinctive behaviour or strategies to resolve failure to attach in the first few days after birth, from the perspectives of mothers and midwives. These topics were therefore explored in detail in the qualitative study. Few mothers recruited to my study experienced instinctive behaviour and successful attachment (in SCT enactive behaviour) at birth. The majority of mothers did not experience attachment at birth and struggled to persist and maintain their motivation to enable breastfeeding initiation in an unfamiliar environment. Midwives’ social expectations and environmental circumstances made women centred care difficult. Midwives considered that sleepy babies who were unable to feed were normal, but women were unprepared for this, compounding the difficulties in initiating breastfeeding. The triangulation of the findings from the systematic review and the qualitative study provide a more complete picture of contributory factors to understanding of difficulties in breastfeeding initiation. Conclusion: It is recognised that behaviour interacts with emotions, perceived abilities and the environment, as in triadic reciprocal causation, which affects peoples’ decisions, experiences and abilities to enable the successful initiation of breastfeeding. Social Cognitive Theory could be used as a framework to develop strategies and materials to enhance women’s confidence both antenatally and in the postnatal period. In a minority of women, breastfeeding goes well and is more likely when the baby is an active participant and the midwife a knowledgeable and confident supporter. This is not the case for the majority of women and babies or their midwives. There is a need to consider strategies to develop appropriate skills and environmental changes that would in turn lead to changes in behaviour and successful interventions. More emphasis should be made clinically on facilitating instinctive behaviour. The current position where babies’ sleepy behaviour is considered normal in this particular environment could be challenged. Social Cognitive Theory could be utilised in research to develop strategies to increase women’s and midwives’ confidence specifically in initiation