Nursing and Health Sciences (2012), 14, 133135

Best Practice Information Sheet

Best Practice Information Sheet: Womens perceptions and experiences of breastfeeding support
nhs_679 133..135

Abstract

According to the World Health Organization, although breastfeeding has signicant health benets for infants and mothers, rates of breastfeeding remain lower than recommended. Suggested strategies for assisting new mothers with breastfeeding have included both peer and professional support. We undertook a systematic review, which included 31 qualitative papers and explored womens perceptions and experiences of professional or peer breastfeeding support. This review identied strong evidence for adoption of models and arrangements that emphasize relationship-based care by facilitating provision of more continuity of care and individualized care and advice for women; practical help for women who need it; antenatal education; postnatal advice and support; midwifery/nursing education to enhance communication and information provision skills; and support schemes that cater to women from all socio-economic groups. breastfeeding, evidence, experiences, qualitative, support, systematic review.

Key words

BACKGROUND
Breastfeeding has signicant health benets for infants and mothers yet, despite global policies to promote it, the rates of breastfeeding remain lower than recommended (WHO and UNICEF 2003). Assistance with breastfeeding is one of the commonest postnatal care needs of women. Both peer and professional support are reportedly important to the success of breastfeeding (Britton et al., 2007). Research suggests that poor support may contribute to early cessation of breastfeeding (Hoddinott & Pill, 2000; Mozingo et al., 2000; Sheehan et al., 2009). Breastfeeding support provided by health professionals has been described both positively and negatively; they are often unable to provide the support women need. In regard to breastfeeding, peer supporters have been identied as positive role models for women. A review of trials comparing additional support for mothers with standard maternity care found that all forms of additional support increase the duration of breastfeeding (Britton et al., 2007). What is not known is the key components or elements of support that are effective in increasing the duration of breastfeeding.

Peer support: support provided by means of a peer support project or scheme, either paid or voluntary. Peer supporters are not part of the womans own informal social network, such as family and friends.

OBJECTIVES
The purpose of this Best Practice Information Sheet was to synthesize the best available qualitative evidence on womens perceptions and experiences of both professional and peer breastfeeding support to identify what women nd supportive and the differences between professional and peer support.

TYPES OF PARTICIPANTS
Studies of both primiparous and multiparous women who had initiated breastfeeding were included in the review. Studies that include a specic demographic sub-group, such as adolescents, were also included. Studies focused on a specic clinical sub-group, such as post-caesarean women, were not included.

DEFINITIONS
For the purposes of this Information Sheet the following denitions have been used: Professional support: support provided by a variety of medical, nursing and allied professionals (Britton et al., 2007).
Correspondence address: The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, South Australia, 5005, Australia. Email: jbi@ adelaide.edu.au This information sheet was rst published at: http://www.joannabriggs.edu.au The Joanna Briggs Institute. Womens perceptions and experiences of breastfeeding support. Best Practice: Evidence-based Information Sheets for Health Professionals. 2010; 14(7): 14. Received 14 December 2011; accepted 2 January 2012.

QUALITY OF THE RESEARCH

Primarily qualitative studies were included in the review. Studies such as large scale surveys were also included if they reported analysis of qualitative data gathered through open ended responses or included in-depth interviews in sufcient detail. A primary and secondary reviewer appraised each paper independently. First, the primary and secondary reviewer compared and discussed their ndings to resolve any discrepancies. Then, where they had not reached agreement, they discussed their ndings with other review panel members. doi: 10.1111/j.1442-2018.2012.00679.x

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Thirty-one papers were included. These were generally of reasonable quality in terms of clarity, appropriate methodology, credibility and evidence cited to support the conclusions drawn. However, most papers included relatively limited discussion of theoretical or conceptual perspectives, discussion of relevant literature and reection on the roles of the researchers. Because most studies identied were UK or USA based, it cannot be assumed that the ndings will apply to other countries with different culture and healthcare system.

Disconnected encounters
In disconnected encounters, there is no sense of having or building a relationship and there is a lack of rapport. This inhibits learning and leads to women lacking condence and being less likely to sustain breastfeeding. Health professionals may not have intended to provoke guilt, or blame women for their problems, however a critical manner or use of words was often perceived this way, especially when women were feeling vulnerable, uncertain and physically and emotionally tired. Some studies identied womens experiences of feeling pressured to breastfeed. This differed from giving positive encouragement in that it tended to make women feel guilty and discouraged them from breastfeeding. It was common for women to report that the hospital staff were too busy with other women and tasks to be able to spend the time needed. They did not perceive this as being a fault of health professionals but more a limitation of their work environment.When women were aware of the pressures on health professionals, they tended to struggle on quietly. If health professionals did give attention or help to individual women, the women often perceived this as rushed and unhelpful. While women strongly valued hands-on proactive approaches, some women felt as though they were being treated roughly when professionals helped in a hands-on, practical way that was rushed and not based on a rapport or relationship.

FINDINGS
The meta-synthesis of the studies included in the review resulted in four categories comprising 20 themes. The review indicates that support for breastfeeding occurs along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as being ineffective or even discouraging and counter-productive. Secondly, the review identied a facilitative approach, which women found helpful, versus a reductionist approach, a contrasting style of support, which women found unhelpful.

Authentic presence
Authentic presence creates a trusting relationship or connectedness between the woman and her carer/supporter. The supporter or health professional makes their availability explicit in a genuine/sincere way and there is rapport. Conveying an authentic presence helps to ensure that the support given is appropriate to the womans needs, and enhances its perceived effectiveness. An authentically present health professional or supporter conveys to the woman that she is available for her when needed, that this can be either in the hospital setting or at home, and can occur despite postnatal wards being very busy. An empathetic approach is an important determinant of whether women feel any help offered is supportive and is linked to taking time, listening and having a warm and positive approach. Being given sufcient time was important to women as it made them feel relaxed and comfortable and helped practically. According to the surveyed women, an advantage of peer supporters is that they are able to spend sufcient time with them to make a difference. Having plenty of time also makes it easier to ask questions of the supporter or health professional. Afrmation, reassurance and encouragement were very important to the women as many lacked condence and found early parenthood very challenging. Listening and being responsive to the womens needs was also highly valued. Authentic presence is more likely to occur where women have the opportunity to build or to have a relationship with the carer/supporter, someone she can relate to and with whom she can share experiences. Women receiving peer support more commonly described having a relationship and their supporter being there, but was not exclusively so. 2012 The Joanna Briggs Institute

Facilitative approach
A facilitative style enables people to draw on a range of information and experience and supports them to learn for themselves. Women viewed this as a positive form of support. A key feature of a facilitative teaching or support style is that information does not all go one-way. Rather, there is an interaction and a dialogue is created between the learner and the teacher, enabling the learner to raise topics, ask questions and discuss issues or concerns. The style and manner in which supporters offered information, help and support was central to womens perceptions of support. Women valued information that was both positive and realistic highly. Women appeared aware that breast is best and knew about some benets, but not necessarily all. Many wanted far more detailed information and to gain a good understanding of the range of benets and the mechanisms of breastfeeding. The surveyed women valued practical help, which included observing feeding and demonstrating techniques and approaches that may be helpful. Sufcient time was needed to enable this.

Reductionist approach
The converse of a facilitative style is a reductionist style or approach. This can reect personal style or lack of effective training in how to provide education or support, but is more likely to be caused by environments that do not facilitate opportunities for professionals and supporters to work in facilitative ways.

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The health professional or supporter not listening and asking, but presuming and telling, characterizes a reductionist style of interacting with women. Women often complained of conicting advice given in busy clinical situations where advice was given in a standardized and directive way, care was fragmented and there was little opportunity for forming relationships. A number of women described feeling confused or stressed by conicting advice given on issues such as positioning and latching, supplementation, length and timing of feedings, hand expression, nipple shields, reux and colic, mastitis, infant weight loss, and milk supply. Many women described supporters giving them standardized advice that was not appropriate to their situation. With reductionist approaches, many women did not get information in an effective way, and often felt confused or undermined.

Grade B Grade C

Moderate support that warrants consideration Not supported

ACKNOWLEDGMENTS
This Best Practice Information Sheet was developed by the Joanna Briggs Institute with Thames Valley Centre for Evidence-Based Nursing & Midwifery, a collaborating centre of the Joanna Briggs Institute, with the assistance of an expert review panel: Associate Professor Patricia McInerney, The Witwatersrand Centre for Evidence-based Practice; Centre for Health Science Education, University of the Witwatersrand, Johannesburg, South Africa Ms Diana Langton, Clinical Midwifery Consultant Breastfeeding, Breastfeeding Centre WA, Australia The New Jersey Center for Evidence Based Nursing: A Collaborating Centre of the Joanna Briggs Institute, University of Medicine and Dentistry of New Jersey School of Nursing, Newark, NJ, USA

RECOMMENDATIONS
Services should adopt models and arrangements that emphasize relationship-based care by facilitating the provision of more continuity of care and individualized care and advice for women. (Grade A) Supporters need to spend time and provide practical help to those women who need it. (Grade A) Antenatal education and postnatal advice and support need to be more learner-centered, and should provide women with information that is realistic, detailed and positively encouraging. (Grade A) Midwifery/nursing education needs to develop midwives/ nurses communication and information giving skills more fully. (Grade A) Schemes to offer peer support should be developed further and include women from all socio-economic groups and these schemes effectiveness should be evaluated. (Grade A) Grades of Recommendation (The JBI, 2006) Grade A Strong support that merits application

REFERENCES
Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers (review). Cochrane Collab. 2007; 4: 161. Hoddinott P, Pill R. A qualitative study of womens views about how health professionals communicate about infant feeding. Health Expect. 2000; 3: 224233. Mozingo JN, Davis MW, Droppleman PG, Merideth, A. It wasnt working: womens experiences with short-term breastfeeding. MCN Am. J. Matern. Child. Nurs. 2000; 25: 120126. Sheehan A, Schmied V, Barclay L. Womens experiences of infant feeding support in the rst 6 weeks post-birth. Matern. Child. Nutr. 2009; 5: 138150. The Joanna Briggs Institute (JBI). Systematic reviews the review process, Levels of evidence. 2006. Available from URL: http:// www.joannabriggs.edu.au/pubs/approach.php. WHO and UNICEF. Global Strategy for Infant Feeding and Young Child Feeding. Geneva: WHO, 2003.

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