The health advantages of breastfeeding are widely documented (Fishman, 2010; Oddy et al, 2011), and the role health professionals play in promoting breastfeeding is also well established (Lawrence, 2010). There is evidence to suggest that support from a skilled health professional can have a positive effect on initiation, duration and experiences of breastfeeding (Battersby, 2014). To provide standardisation and quality support offered by health professionals, UNICEF and the World Health Organization founded the Baby Friendly Hospital Initiative in 1991 to appropriately train professionals (UNICEF, 2014).
Uniformity of positive attitudes, knowledge, and promotion behaviour is the objective of health services, and is expected and assumed by many policies (Scottish Government, 2011). Often there is little or no consideration of the attitudes of professionals and the role this may have in promotion in breastfeeding policy frameworks. Although views regarding breastfeeding are generally positive, positivity is not universal. Tennant et al (2006) found concerns among health professionals about practice sometimes running counter to the evidence-base, while Cockerham-Colas et al (2012) found negative attitudes towards extended nursing.
Often, unhealthy choices of the public are attributed to unhelpful health beliefs, and much health promotion focuses on altering these beliefs (Bartholomew et al, 2011). In contrast, health professionals are frequently described as having professional beliefs, which are assumed to be consistent, evidence-based, and rational (Houser and Oman, 2011). However, they are prone to the same phenomena that characterise all human psychology, and thus their health beliefs may also be formed by factors other than research-based evidence.
Although the importance of knowledge has been underlined, knowledge of the benefits of breastfeeding alone is not sufficient to provide breastfeeding support; a positive attitude is also essential (Battersby, 2009). A number of studies have evaluated attitudes, beliefs, and breastfeeding knowledge of health professionals. Ekstrom et al (2005) found general positive attitudes towards breastfeeding across a variety of professional groupings. Darwent and Kempenaar (2014) found that peer supporters and student midwives had overwhelmingly positive attitudes towards breastfeeding. Many other studies describe the majority of professionals reporting a positive attitude to breastfeeding (Bagwell et al, 1993; Chen et al, 2001; Spear, 2004).
However, few studies, to date, have qualitatively investigated the nature of professionals’ beliefs (Furber and Thomson, 2008), instead relying on simple statements of support or agreement. It is unclear how much these reported beliefs reflect the depth, nature, and complexity of attitudes. The analysis of attitudes in much literature can be seen as being mainly descriptive.
There is a lack of qualitative studies that explore extensively the breadth and depth of health professionals’ attitudes in this domain, and no valid and reliable quantitative tool exists to measure professionals’ attitudes towards breastfeeding. Given these issues, it is important to investigate in a qualitative manner health professionals’ views regarding breastfeeding promotion, to obtain a clearer image of the depth, nature, and complexity of underlying attitudes.
Aims
The aim of this study was to explore the nature of the beliefs and attitudes of health professionals towards breastfeeding and breastfeeding promotion.
Design
This was a qualitative study that used a series of focus groups with health professionals to discuss their views regarding breastfeeding. Thematic coding of content was conducted to elucidate elements of breastfeeding promotion practice and culture. A constructivist approach was adopted in the understanding of how knowledge and meaning are created.
Participants
Participants were recruited from a Scottish NHS Board through non-random purposive sampling given their profession (i.e. involvement in promoting breastfeeding). The group of women the participants care for covers the broad spectrum of pregnant mothers. Although focus groups took place mainly with separate NHS staff teams, deliberate effort was made to include groupings of mixed professionals wherever possible to generate discussion about the themes from different perspectives.
A total of 51 participants took part. The rationale for participant numbers was to be led by data saturation, and this was achieved. All participants were female; of the male staff who were approached, none chose to take part. All volunteered to take part—none were instructed by management to take part. The largest profession group was health visitors (n=22; 41.5%), there were 10 community midwives (18.9%), and 10 hospital midwives (18.9%). Several other professions were also represented, including school nurses (n=4; 7.5%), and public health practitioners (n=5; 9.4%), as well as one team nurse (1.9%) and one nursing assistant (1.9%). In addition to their current roles, many participants had practised in more than one role during their careers.
Data collection
Procedure
Contacts were established with relevant departments and requests for participants were made. Staff were sent invitations and an information sheet explaining the nature of the study. The data were collected by the lead author, a male trainee health psychologist. Once groups were assembled, the aim of the study was verbally described to participants, with the information sheet again being given. Participants were informed that all participation was voluntary, and that data would be presented anonymously.
Focus groups
Evidence suggests that focus groups are a valuable means of capturing experiences (Kitzinger, 1995).
Focus groups took place in meeting rooms across various NHS settings, depending on convenience for participants. Open-ended questions were designed to elicit beliefs and attitudes towards breastfeeding promotion (Figure 1). These questions were intended to facilitate participant-led discussion, with the facilitator asking additional questions to develop concepts. Questions were developed through a piloting process, whereby four senior midwifery staff were consulted regarding question wording.
Ten focus groups were carried out, lasting between 36 and 77 minutes, and were transcribed verbatim to provide an accurate representation of participants’ utterances, and to convey their original meaning (Braun and Clarke, 2006). Groups varied in size between three and 10 individuals, and consisted of a mix of professions in each. All groups were audio recorded and transcribed by the lead author.
Ethical considerations
The project was granted ethical approval as Service Development by the local NHS Ethics Committee, and all procedures were performed in compliance with NHS Ethical Guidelines.
Data analysis
Thematic analysis was used to identify and report themes. This involved creating and applying a coding system to data to highlight important themes. Meanings, experiences, and reality of participants were described, to recognise how individuals make sense of their experiences, and how societal contexts affect those meanings.
Thematic analysis involves six phases (Braun and Clarke, 2006) beginning with searching for areas of interest and patterns of meaning within the text. The process was completed by these patterns being clustered into themes. Data were transcribed—itself an integral phase of analysis (Bird, 2005). It is important to note that transcriptions can never be a wholly objective account of reality (Maxwell, 2013), but rigorous transcription is a fundamental cornerstone of analysis.
Results
Three main themes, each with several sub-themes emerged from the data (Table 1).
| Main theme | Sub-themes |
|---|---|
| 1. Powerlessness and pessimism driven by others’ impact | 1.1 Significant others |
| 1.2 Partners and grandmothers | |
| 1.3 Family norms and support | |
| 1.4 Peers and cultural norms | |
| 2. Breastfeeding promotion vs coercion and education | 2.1 Overzealous breastfeeding promotion |
| 2.2 The legacy of historical professional practice | |
| 2.3 Moral judgement | |
| 3. The position of breastfeeding promotion within practice | 3.1 Prioritising attachment and aspects of mothers’ health care |
| 3.2 Questioning their role in breastfeeding promotion—diffusion of responsibility |
Powerlessness and pessimism driven by others
Participants felt that in the face of external factors, their contribution to feeding choices is diminished. This pessimism led to feelings of powerlessness and lack of control.
Significant others
The prevailing attitude of health professionals was that there was a hierarchy of influences on mothers, and that they themselves (and the health service in general) had a minor part to play. These were:
Partners and grandmothers
Professionals felt that partners’ perceptions of breasts as having primarily a sexual (rather than a feeding) function, and partner support, influenced feeding decisions. In a most candid way, males can feel ‘ownership’ of the woman's breasts, perceiving the child as a rival:
‘Sometimes also the partner's views that the breasts are his and not this baby who's coming along. That's another issue for women is that partners don't want them to do it.’
Grandmothers’ role was emphasised. Pressures on young mothers caused by absent fathers, financial hardship, and lack of wider family support results in grandmothers assuming responsibility in raising the child, resulting in less opportunity for the mother to breastfeed:
‘They get pregnant, the guy's off … this was an unplanned pregnancy and they just think, “Well you know, I'll hand this baby over to my mum or whoever”. And the granny is quite happy to take them because that's the kind of way they've been brought up as well.’
Such attitudes were associated with helplessness among professionals, and engender doubt regarding the impact of their role:
‘You're sitting with grannies in their late 30s. And they have a massive input on these new babies’ lives and if they've all bottle-fed … you know, you're really hitting this stone wall.’
Family norms and support
Professionals felt family norms influenced breastfeeding choices. These norms are transmitted intergenerationally, are resistant to change, and perceived as being an insurmountable barrier to successful breastfeeding promotion:
‘[It's] historical … mum didn't breastfeed. Grandmother didn't breastfeed. They bring the baby home and breastfeeding isn't an option. It's a historical thing … and that's obviously influenced by the extended family—it has a huge influence.’
Many participants believed the family plays a more influential role than professionals and the health service. A feeling of helplessness pervaded:
‘We are a very small part of that [breastfeeding promotion], what really needs to happen within pushing for breastfeeding as actually a society. As a society, communities and families.’
Peers and cultural norms
In addition to families, it was felt peers’ normative behaviour played a role in influencing social norms, though not as much as families:
‘I think the way forward for supporting breastfeeding—especially young mums—is other young mums who've managed it, and know the problems and the pitfalls, and know how hard it is. I don't think that middle-aged women [can help].’
Perceived societal and cultural norms elicited from television and ‘celebrity culture’ also had an impact. It was felt that the most effective route of breastfeeding promotion would be to alter perceived peer norms through television, rather than promoting directly.
‘Breastfeeding … it's not the done thing. You know, they're (teenagers) looking at things like celebrities and all these kind of programmes and they don't see them breastfeeding … they don't have that connection and I think teenagers now need that connection.’
Breastfeeding promotion vs coercion and education
Many participants had extensive professional experience and expressed some ambivalence regarding how the health/social care professions promoted breastfeeding.
Overzealous breastfeeding promotion
There were wide-ranging attitudes regarding the ‘breastfeeding promotion movement’—the culture surrounding promoting breastfeeding. Overzealous promotion of breastfeeding was seen as self-defeating, making mothers feel inadequate, guilty, and shameful, resulting in mothers not ‘enjoying their baby’, which was seen as the antithesis of their goal as health professionals. Indeed, the negativity that could be conveyed by incorrect promotion styles can be overwhelming. As a result, some professionals reported taking (or wanting to take) active action to stop some breastfeeding promotion practices:
‘I was in Glasgow the other day and honestly, there was tannoys going on about “Breast is Best”. And I thought, “You know, this is becoming so negative”. It really, really is. Breast is best but it's not explained to people actually why … they just keep shouting “Breast is Best”. And I think people get to the stage, as you say, they switch off to it. Honestly, see in Glasgow when it was getting tannoyed in Argyll Street–if I'd a towel I would have thrown it over the tannoy. I thought, “Please, just give us a break”.’
One participant reported actively taking down promotion posters in clinics, as they made bottle-feeding mothers feel inadequate:
‘I think it's quite hard for people that really want to bottle-feed have a big hang up about bottle-feeding. I don't like those posters up I have to say—say, offering clinics on breast is best. I feel for the girls that are bottlefeeding … I don't like that way of doing it….I mean, fair enough in the Health Centre but not in the clinic room where they come in, these mums come in. The midwife leaves them all, I take them down because I think 9 out of 10 are coming here probably bottle-feeding. I've got enough problems with them without [them] feeling guilty. In the Health Centre, that's different but not where I've specifically got the bottle-feeding mums.’
Overzealousness of promotion also stretched to some breastfeeding support groups (designed to support breastfeeding mothers), which could be overly aggressive in their promotion:
‘No offence to the support groups but some of them are a bit radical, and if you are a wee 15/16 year old. I've had two 15/16 year olds that breastfed but they were from really close-knit supportive families. That was their support not, I mean, if you put them to some of these groups where they are a wee bit off the wall…’
The legacy of historical professional practice
An important cultural phenomenon was the impact overzealous health promotion had on norms of past generations:
‘Mums can accept that [the benefits of breastfeeding], but it's the grans who look at the charts and say, “oh he's no getting enough. I don't care what that woman [the health professional] says, they should be getting this [formula milk]” … they're so weight conscious. I mean we drove that into them in a past generation.’
It was believed that attitudes of health professionals in previous generations strongly influenced mothers’ experiences of breastfeeding at that time. This ingrained a negative attitude towards breastfeeding in these women, who passed this attitude on to their children:
‘Midwives promoting negativity … my mother went through life, you know, waking up during the night thinking about Sister X [midwife in the locality practising in the 1950s and 1960s], who lots of people talk about even now. But they were absolutely terrified by this midwife at X Clinic who threw children back at you and said “your baby's got nothing again”. Test weighed every single feed and that was huge negativity in this area.’
Moral judgement
Participants were keen to illustrate the damage to the staff–patient relationship that could be caused by overzealous promotion and moral judgement:
‘I give information on breastfeeding and bottle-feeding because obviously we will, we will give them information on both. And I say to them, ‘as a midwife it is my job to give you the information’ and they will, they are quite happy to sit and listen to that information. And I have bottle-feeders that say, “Yes but I'm going to bottle-feed”. I say, “Absolutely fine, and we will support you in bottle-feeding.”’
It was seen as important to avoid moralising breastfeeding, and risk alienating the mother. Breastfeeding was seen as a personal choice bound up with ideas of moral judgement:
‘That's [feeding choices] entirely up to them. I always say to them you're a good mother whatever you do. I always say that to them.’
The position of breastfeeding promotion within practice
There were various viewpoints expressed regarding how breastfeeding promotion should be delivered, and how high a priority breastfeeding should be.
Prioritising attachment and aspects of mothers’ health care
Participants felt that child–mother attachment and wellbeing was the highest priority, and that the professional–mother relationship is also important. Overzealous promotion could result in damaging these relationships, through mothers feeling guilty or pressurised. Therefore, professionals did not wish to moralise breastfeeding:
‘We're not going to get them to breastfeed to the detriment of their mental health and their wellbeing. They need to enjoy their baby … Midwives and the breastfeeding [councillors] are known as the Gestapo. I mean that's how patients describe midwives, not just in [this specific area], in other hospitals as well … If you don't breastfeed, they're not interested in you, and that is dreadful.’
Questioning their role in breastfeeding promotion—diffusion of responsibility
At each stage of care, it was felt that promoting breastfeeding was largely futile and ineffective, as feeding decisions had already been taken. This attitude was prevalent throughout all profession groups:
‘You can spin the odd one, but the vast majority—before they've even conceived—have made up their minds how they are going to feed.’
The belief that breastfeeding promotion is most effective in very young children was prevalent:
‘I think we need to educate the schools especially, we need to get into the schools and educate. By the time they are 16 or 17, it's too late … you could do health promotion right from early primary school … children go to pre-school now at 3, health promotion starts at 3 when they get into the education system. So that's where it should be starting.’
‘We do start [breastfeeding promotion] in primary 7. But by primary 7 they're already thinking about body identity, etc, so maybe something a wee bit earlier on.’
A view expressed by many health visitors was that breastfeeding promotion had almost no part in their role. They saw their role as purely supportive because they do not meet the mother and child until around the 11th day postnatally. By then breastfeeding had been established. However, they reported that the Trust included them in policy development regarding breastfeeding, and regularly attended education and training on the topic. This seemed to be an area of confusion:
‘There's no way you can increase the breastfeeding rates when you are going into somebody whose baby is 11 days old because the decision has been made about feeding.’
Midwives also had issues regarding the responsibility and stress of having to promote breastfeeding. They felt they had so many other demands on their time, that in some cases they would rather mothers did not breastfeed, so as to relieve stress:
‘In the hospitals quite often they are often so rushed, so busy, that it is sometimes a case of, “Please don't say you want to breastfeed, because this is going to take a lot of time and effort,” and we know that happens.’
Discussion
The range of pressures on health professionals, coupled with time constraints, and shifting demands driven by a perpetually changing policy landscape makes for a challenging role. Similar to other studies, professionals felt that support issues were important in influencing breastfeeding decisions (Battersby, 2002; Brown et al, 2011).
There are issues for consideration by practitioners and policy makers. Beliefs can be understood using a social learning model of breastfeeding, whereby mothers model their behaviour on the live, verbal, and symbolic norms surrounding them. Participants perceived many cumulative influences on these norms, resulting in a lack of belief in their own effectiveness, and of perceived control. Various studies note how lack of perceived control can impact behaviour (Ajzen, 2011; McEachan et al, 2011). The results suggest that with reference to breastfeeding rates, professionals place their locus of control externally. Control of breastfeeding lies with others (grandmothers, partners, family members) or cultural forces, diminishing their perceived internal control.
While external factors influence mothers’ choices, research has demonstrated the impact good patient–professional communication can achieve (Rao et al, 2007; Battersby, 2014). The results of this study imply that this needs to be emphasised to those working with women making breastfeeding choices. Interventions to increase self-efficacy, such as positive feedback, could have an impact on this.
Traditionally, breastfeeding promotion campaigns have targeted mothers (Pérez-Escamilla and Chapman, 2012). Promotion tailored towards significant others could prove a fruitful avenue, with positive attitudes in these populations resulting in increased breastfeeding and less hopelessness within the professions.
Participants’ belief in the paucity of their impact could be interpreted as a professional ideology, perpetuated through collegiality (Padgett, 2013). If a feeling of hopelessness pervades a locality or profession, this may lead to an acceptance of a position where breastfeeding is promoted without any expectations of effectiveness, and a collective value can emerge where low breastfeeding rates are acceptable (West and Dawson, 2012). This value appeals to new professionals as it alleviates guilt and disappointment in low breastfeeding rates, addressing cognitive dissonance.
Breastfeeding promotion vs coercion, and education
Overzealous promotion was seen as making mothers feel inadequate. As a result, some professionals reported taking action to stop some breastfeeding promotion practices.
There have been feminist critiques of breastfeeding, asserting that breastfeeding may not be ‘empowering’ (Carter, 1995; Murphy, 1999) for all mothers, with the moral discourse surrounding breastfeeding potentially having a negative impact on mothers (Crossley, 2009). Research has focused on the science behind breastfeeding (Fishman, 2010; Battersby, 2014), resulting in a growing association between breastfeeding and being a ‘good’ mother (Lee and Furedi, 2005; Crossley, 2009). However, some authors suggest breastfeeding has been too forcefully promoted, resulting in breastfeeding being imposed with ‘religious-like fervour’ (Schmeid et al, 2001; Kvist et al, 2006). This may be the root of the ambivalence expressed.
One of the main reasons for wishing to avoid morally judging mothers’ choices was to protect the patient–professional relationship. This should indeed be a priority, as a positive alliance can predict a range of outcomes (Fuertes et al, 2007; Zeber et al, 2008).
Participants felt breastfeeding promotion should have a different role from that advocated by the health service—to ‘educate’ about, rather than ‘promote’ breastfeeding. Once a mother had sufficient information and her decision made, any effort to promote breastfeeding could be dismissed. However, it is difficult to ascertain what constitutes ‘sufficient information’; whether this should be measured by merely acknowledging there is a decision to make, being aware in a general sense that ‘breast is best’, or to fully comprehend the implications of the choice (Anderson et al, 2002).
Parent–child attachment was seen as a priority that should not be endangered. Participants were anxious that mothers experiencing ‘pressure’ to breastfeed would have an impact on their mood, resulting in jeopardising their chances of forming secure attachments. Professionals are correct in underlining the significance of attachment for long-term wellbeing (Kim et al, 2012), although it is unknown if there is any grounding for this expressed fear.
Moralising
Participants were wary of moralising breastfeeding. The weight of evidence for breastfeeding appears conclusive, and, as Crossley (2009: 72) points out, ‘the rhetoric of the “natural” has proliferated’ discourse regarding breastfeeding. This strong connection between breastfeeding and being perceived to be a ‘good’ mother results in breastfeeding becoming a moral imperative, although this narrative appears to be largely ignored by breastfeeding promotion literature, and requires further examination.
Diffusion of responsibility
The futility felt regarding promotion was compounded by the belief that feeding decisions had already been taken before mothers accessed services. The consequential belief was that breastfeeding promotion should happen earlier, with responsibility lying with early-life workers. If indeed breastfeeding decisions are made before the point at which promotion is currently concentrated (i.e. after conception), this needs to be addressed. Attitudes of young people are more malleable than adults (Crano and Prislin, 2008), and the suggestion that promotion efforts should concentrate on young people has merit.
The issue of where professional responsibility for breastfeeding promotion should lie is important to address. Participants seemed keen to place this with others rather than themselves. Diffusion of responsibility is a psychosocial phenomenon where the presence of others (and the belief that the responsibility to act lies with those others) reduces the probability of an individual acting (Guerin, 2012). This may be used to explain attitudes towards breastfeeding promotion. The ‘presence’ of other professional groups in the process of making feeding choices (from primary school educators though to postnatal carers) meant that promotion was less likely to be the priority of any one person. Explicitly locating responsibility with one professional group may help combat this phenomenon.
Implications
Although some positive attitudes were expressed in the focus groups, feelings of hopelessness, futility, and resignation need to be addressed. This could be achieved through training about attitude formation and its influence on behaviour. Learning outcomes should focus around developing a shift in locus of control from external to internal to foster a belief in professions’ own abilities.
The results suggest discussion is still needed within health professions as to the precise role health care has in the promotion of breastfeeding (Johansson et al, 2010). While policy makers and promotion specialists may be clear on the role of promotion, those in care professions may have a differing vision. A wide debate is needed to clarify the role of health promotion messages and their function.
The distaste for overzealous breastfeeding promotion is an issue that needs to be addressed. Further research is needed to explore why some promoters are seen as overzealous, and to discover if indeed promotion occurs in a manner contrary to evidence on attitudinal and behavioural change.
According to professionals, a constituted effort should be made to normalise breastfeeding by highlighting it in TV and ‘celebrity culture’. Ultimately, this is a decision for implementation at governmental level, although experts have opportunities to use their status to petition governmental policy makers and budget holders.
Currently, there is little research investigating the role of the therapeutic alliance in maternity settings and more is needed to establish the impact of the therapeutic alliance in this setting. Due to the lack of evidence, any conjecture regarding whether the therapeutic alliance is jeopardised by breastfeeding promotion is of limited value.
Limitations
Given the emphasis placed on the personal experience of the clinician in relation to this issue, the fact that the researcher was both male and childless may have resulted in the researcher being attributed ‘outsider’ status in the minds of participants, and may have affected participants’ responses. The participants’ focus on teen mothers in many of their statements may mean these results have a particular relevance for this demographic. In addition, data being collected within the context of the participants’ professional role and environment may result in more guarded answers being given than would be optimal. Taking these into consideration, perhaps the candid nature of the discussions should be see as all the more noteworthy.
Conclusion
The current study found a range of attitudes expressed regarding breastfeeding promotion. Professionals were positive in their attitudes; there was no debate around whether breastfeeding was better than bottle-feeding. However, to merely report attitudes as positive or negative is simplistic. Professionals frequently diminished their own role in mothers’ choices, citing a host of other factors outside their control that had more sway over mothers. The result was a lack of hope that breastfeeding rates could change as a consequence of their actions.
These attitudes surfacing in many individuals may facilitate norms, inherited by new professionals through principles of social learning theory. These issues could be addressed through training of staff to raise awareness of psychological processes that can have an impact on breastfeeding promotion behaviour. In addition, making more use of cultural role models and media may influence social norms.