Providing Breastfeeding Support : Experiences from Child-Health Nurses

Background: Breastfeeding problems are common during the early period but can often be prevented or overcome with adequate support. Child-health nurses meet almost all children during their first weeks of life and play an important role in promoting breastfeeding and in strengthening parents’ confidence and their belief in their own ability. It is, therefore, important to gain more knowledge about child-health nurses’ experiences. Objective: To describe child-health nurses’ experiences of providing breastfeeding support. Methods: This qualitative study is descriptive with an inductive approach. A purposive sample of eight child-health nurses recruited from district health care centers participated. Data were collected through focus group interviews and analyzed with content analysis. Results: Child-health nurses consider it to be important to provide early breastfeeding support and that early hospital discharge following birth can complicate breastfeeding. Furthermore, the introduction of infant formula and tiny tastes given to the baby can be a barrier to breastfeeding. Parents’ confidence had an effect on breastfeeding, and breastfeeding is promoted by confident parents. Trends and cultural differences have an influence on parents’ attitudes toward breastfeeding. Child-health nurses stated the importance of having a consensus breastfeeding policy. Conclusion and Recommendation: A number of factors affect breastfeeding, and breastfeeding support from child-health nurses is important in the early stages after birth. To conclude, the support must be individually tailored with a focus on the parents’ needs. There is a need for greater cooperation between the maternal care and child-health care staff in order to provide adequate and continuous breastfeeding support throughout the care chain.

The breastfeeding rate in Sweden has fallen slightly each year since the mid-1990s.The frequency appears to decrease the older the child is, which may be caused by the fact that women nowadays nurse their babies for a shorter period [1].There are regional differences as well, and a possible explanation may be that there are different breastfeeding promotion efforts in different parts of the country [1].A study [2] shows that breastfeeding frequency is influenced by women's social and economic status.In Western countries, highly educated women and women with a partner were more likely to breastfeed their infants than women with less education and those who are single [2].A report from the National Board of Health and Welfare shows that breastfeeding has decreased in all social classes of mothers and children [3].Therefore, it is important to strengthen breastfeeding support to all new mothers, and vulnerable groups should continue to receive extended support.The World Health Organization recommends breastfeeding exclusively *Address correspondence to this author at the Division of Nursing, Department of Health Science, Luleå University of Technology, SE-97187 Luleå, Sweden; Tel: +46 920 493856; E-mail: Birgitta.Lindberg@ltu.se during the infant's first six months [4].Breastfeeding benefits the health of the mother and the child in both the short and long term.Breast milk is adapted to the needs of the developing infant, and its composition changes as the child grows.Breast milk contains substances that stimulate the child's immune system and reduce the risk of infections.Moreover, breast milk and breastfeeding may offer protective benefits against illness later in life, for example, in regard to obesity and diabetes.Breastfeeding is also a protective factor for SIDS.For the mother, breastfeeding can reduce the risk of diabetes and ovarian and breast cancer [5].Zwedberg states that breastfeeding has additional benefits beyond simply feeding the baby; it also promotes bonding between mother and baby [6].
In spite of its various benefits, breastfeeding problems are common during the early period but can often be prevented or overcome with adequate support [7].Several studies [8][9][10][11] show that mothers can experience a lack of breastfeeding support from health care professionals.Lack of support from family and health care professionals was one of the main reasons for women to stop breastfeeding during the first ten days after birth [2].In one study [11], mothers described that breastfeeding affected their experience of parenthood.Feelings of isolation and loneliness related to breastfeeding were common, and for many women, breastfeeding-related problems were experienced as failure.Some mothers experienced breastfeeding as a societal pressure, and for many it was associated with problems; therefore, it required great self-confidence not to give up.Furthermore, several studies [12,13] describe mothers as expressing that an individually designed breastfeeding support program increased their confidence; they also noted the value of confirmation and follow-up.Studies [11,14] highlight that new parents expressed a need for information about breastfeeding complications before the infant was born.Parents were surprised that breastfeeding took time in the beginning, that it could cause discomfort, and that the newborn had a great need for closeness and a varying diurnal rhythm.
A study [9] about barriers to breastfeeding shows that health care professionals experienced shortcomings in their own knowledge about breastfeeding and counseling.Other obstacles reported were a lack of resources and negative attitudes among health care professionals.A thesis [15] shows that personal experiences can influence a health care professional's attitudes toward breastfeeding.Nurses with positive attitudes often provided good support, while negative attitudes resulted in less beneficial support.According to Laanterä et al. [9] nursing staff now and then considers that breastfeeding support does not require scientific knowledge and therefore base their counseling on personal experience.Another study [16] demonstrates that education for health care professionals working with breastfeeding support was effective for improving knowledge and attitudes.
The literature review indicates a gap in the research about child-health nurses' views about breastfeeding counseling.The nurses in child health meet almost all children during their first weeks of life and play an important role in promoting breastfeeding and in strengthening parents' confidence and their belief in their own ability.It is, therefore, important to gain more knowledge about child-health nurses' experiences.Thus, the aim of the study was to describe child-health nurses' experiences of providing breastfeeding support.

METHOD AND DESIGN
A qualitative research design with an inductive approach was chosen to describe child-health nurses' views about providing breastfeeding support.Data were collected through focus group interviews and were analyzed using content analysis.

Participants and Procedure
A purposive sample of 8 child-health nurses (all women) from two different health care centers in the Northern part of Sweden participated in this study.The participants were between 35 and 64 years old and had worked as child-health nurses for 2 to 15 years.Criteria for inclusion were: being a nurse specializing in district health care or child care and working in child health a minimum of 50 percent of full-time work.The childhealth nurses who fulfilled the criteria for inclusion were invited to participate in focus group discussions to discuss their views about providing breastfeeding support.

Data Collection
Two focus group interviews with four child-health nurses in each group were conducted.Focus groups are a form of group interview that has been shown to be effective for the exploration of attitudes and needs [17].The interviews were conducted at the participants' workplace during working hours.An interview guide was used, and the first question was "Tell us about your thoughts and experiences of breastfeeding support".Each focus group interview lasted about one hour.Two researchers moderated, with one facilitating the session by listening actively and guiding the discussions while the other observed, taking particular interest in nonverbal interactions and communication.The interviews were recorded on a digital audio file and transcribed with permission from the participants.

Data Analysis
The transcribed focus group interviews were analyzed using content analysis with an inductive approach in accordance with Graneheim and Lundman [18].The first step was to read the entire text several times to acquire a sense of the contents.Thereafter, meaning units, i.e. words, sentences or paragraphs with aspects related to each other through content and context, that reflected the aim of the study were extracted and then condensed in order to shorten the text but still maintain the essence of the content.Next, meaning units were sorted in several steps based on similarities and differences and were grouped into several categories.This categorization was performed in several stages, with constant reference to the original text to prevent the loss of any aspects of the content.The analysis resulted in six categories.

Ethical Considerations
The study followed the ethical principles of the Helsinki Declaration [19].All ethical standards regarding informed consent and the right to withdraw at any time without repercussions were upheld.The managers of the health care centers involved gave their permission for the study to be conducted.The participants were informed about the study and were reassured that their participation was voluntary and that they could withdraw from the study at any time.They gave their informed consent and were guaranteed confidentiality and anonymized presentation of the findings.Ethical guidelines and rules were continually and carefully considered for the good of the participants and to prevent harm or risks.

RESULTS
The analysis revealed six categories (Table 1).They are presented in the text that follows and illustrated with quotations from the participants of the focus group interviews.

Table 1: Overview of the Categories (n=6) Categories
Providing early breastfeeding support is important

Early hospital discharge following birth can complicate breastfeeding
The introduction of infant formula and tiny tastes can be a barrier to breastfeeding Breastfeeding is promoted by confident parents

Trends and cultural differences influence attitudes about breastfeeding
The importance of having a consensus policy

Providing Early Breastfeeding Support is Important
Child-health nurses described the importance of early support to new parents, which enhanced the possibility of a positive start with breastfeeding.It was important to support the parents during the first days, as there was often a need to strengthen the mother's confidence about breastfeeding and the attachment between parents and infant.Furthermore, child-health nurses' opinions were that breastfeeding was positive for the mother-infant dyad.
Child-health nurses stated the importance of knowing parents' views on breastfeeding, their previous experience, and their motivation for being able to provide individual support.Child-health nurses informed parents about the significance of peace and quiet when initiating breastfeeding.They also gave advice on breastfeeding techniques, and parents were informed about the benefits of breastfeeding e.g.nutrition and emotional attachment.Some nurses informed parents that breastfeeding often is more convenient than bottle feeding.In addition, information was provided about infants' growth, and they gave advice about nursing the baby more often than usual to increase lactation when the infant was going through a growth spurt.Child-health nurses discussed that increasing their knowledge strengthens parents' confidence and prevents them from starting with infant formula.They reflected on the importance of mothers taking care of themselves in order to cope with nursing their babies.In addition, they stressed that it was important to make parents feel welcome to call the child-health nursing staff if necessary or if they needed advice.

Well, you [child-health nurse]
give mothers advice about the importance of eating, drinking and sleeping, and not becoming cold... maybe a little bit about breastfeeding technique so they don't get sore nipples.
Child-health nurses reported that they respected parents' decisions about starting breastfeeding or not, but they wanted to have contact with the parents and give them information and advice before any decisions were made.Their experience was that information about breastfeeding was not given to parents during pregnancy.

Early Hospital Discharge Following Birth can Complicate Breastfeeding
Child-health nurses' experience was that establishing breastfeeding can take time, and based on that, the length of the hospital stay can affect breastfeeding, with early discharge from the hospital having the potential to make it more complicated.Their opinion was that parents need more support for breastfeeding and more advice about caring for their newborn before hospital discharge.Furthermore, child-health nurses emphasized that it would be beneficial for breastfeeding if new parents were allowed to stay at the maternity ward for a few days in order to gain strength, get started with breastfeeding, and become more confident in their parental roles.They were unanimous in their view that early hospital discharge could negatively affect breastfeeding, as many parents lacked support at home.
Yesterdays at the maternity ward, mother was supported with nursing the baby.Nowadays they go home and try by themselves.

The Introduction of Infant Formula and Tiny Tastes can be a Barrier to Breastfeeding
Child-health nurses reflected on the trend to combine breastfeeding and infant formula, which has become more common.Their experience was that infant formula was sometimes introduced to healthy newborns at the maternity ward.Nurses stated that it was a potential problem when parents followed the advice to give their infants formula in cases where the breast milk production had not yet been properly established.They viewed it as much better to wait until milk production has stabilized before giving formula.
In addition, child-health nurses described that parents need information about breastfeeding in regard to its variability.That is, they needed to be advised that for some mothers and infants, breastfeeding can start easily, but for others it can take some time.Therefore, it is important to understand that if the infant is given formula in the days immediately following birth, it can lead to problems when mothers attempt to switch to breastfeeding.They informed parents that healthy infants don't need formula, but sometimes parents did not listen to them, and instead of nursing the baby more often to stimulate milk production, many parents gave the infant formula.

I actually know [a] mother who gave infant formula during growth periods, when the child really should have nursed more. And often, mothers think that they don't have enough breast milk to feed the baby.
Furthermore, child-health nurses' experience was that parents bought infant formula as a form of insurance in order to feel secure if they needed to use it.They described that some parents did not contact the child-health center for practical advice before starting to give the infant formula.They reflected on a common misconception that the addition of infant formula makes the baby sleep better and longer.Childhealth nurses also discussed that some parents felt that it might be convenient to bottle-feed because then they would know exactly what amount the infant had taken.Furthermore, the nurses described that some parents thought that the baby needed to eat every time it cried, and therefore, they tried to give the infant formula.Child-health nurses described that first-time parents were often curious and wanted to give the baby tiny tastes of baby food around the age of four months, while women with prior deliveries were in no rush to feed their babies solid food.

Breastfeeding is Promoted by Confident Parents
Child-health nurses discussed that parents' confidence had an effect on breastfeeding.When parents felt secure and dared to trust in themselves, this had a positive influence on nursing the baby.Conversely, nurses experienced that many new mothers were insecure and had doubts about whether they were producing enough breast milk for the baby.Two frequently asked questions were how much should the infant eat and how do you know if the infant has had enough to eat.Nurses described that it was common for mothers who were expressing breast milk to feel stressed about the amount of milk they collected.A tool used by nurses for supporting parents was to show them their infant's height and weight curve; this was helpful because it made it easy for parents to see that their child was growing properly.

But it depends very much on the parents, very much ... how confident they are in themselves and if they dare to trust themselves -reading the children's signals or interpreting them correctly.
Nurses reflected that many mothers had a mental image of how it would be to nurse the baby, and some were disappointed when breastfeeding did not go as they had expected it would.When breastfeeding did not go smoothly, child-health nurses described that the mothers felt guilty, and the experience negatively affected the mother's self-confidence.Moreover, nurses' experiences were that previous experience with breastfeeding was important for mothers; positive experiences gave them confidence, while difficulties with breastfeeding the first child could result in some mothers deciding not to put any effort into breastfeeding their next baby.

I think it is quite important how you experienced breastfeeding with the first child, or the children before; if it has gone well, and so on, you feel safe in it.
Child-health nurses stated that it was amazing to observe parents' pride and confidence when breastfeeding worked well.They described that some parents wanted to continue breastfeeding beyond six months because it worked well and was convenient.

Trends and Cultural Differences Influence Attitudes about Breastfeeding
Child-health nurses agreed that breastfeeding is affected by trends in society.Their experience was that today's parents wanted to be flexible and to be able to leave the infant with others.They reflected that it was important for parents to have their own activities, and therefore, for practical reasons, some chose to bottle feed the baby.…but no, a mother said, "It's great to be flexible and to be able to leave the child for a while," and, yes, it felt hopeless.They had already decided... Child-health nurses discussed that mothers' relationships with their friends and other mothers also affected their decisions about breastfeeding.They thought that mothers who wanted to stop breastfeeding even though it was working well had sometimes been influenced by others who advised them to give up nursing.The nurses also reflected that some parents might have difficulty adjusting to the parental role and therefore wanted to be flexible.
In addition, child-health nurses stated that some mothers in advance had decided to stop breastfeeding when the baby reached six months of age.They described the mothers having the sense that it felt good to end breastfeeding even though it had worked well.
Child-health nurses experienced that it was rather common for parents to have searched for information about breastfeeding on their own and not wanting to have information from the child-health nurse.The nurses considered that some mothers did not feel confident when breastfeeding in public, and that this could be an obstacle to breastfeeding.Nurses also expressed that in today's society, it is not always acceptable to breastfeed in public.But what's the problem, it's that mothers don't want to breastfeed in public places, but they want to be in public places.It's really hard.
Child-health nurses discussed gender equality as important for many couples.Some parents are equal in terms of child care and feeding the baby.Some parents choose to bottle feed at night so that both parents can participate equally.Nurses also discussed that parents may be motivated in their decision to stop breastfeeding because of their desire for equality.
For the child-health nurses, it was important to express to parents that it is possible for both of them to have an equal part in the baby's care even though the mother is nursing the baby.They wish that couples could find a solution that focuses on their infant's best interests.The nurses also noted that support from the older generation in a family does not exist as it did in days gone by; some parents had no network of family members nearby who could help them with advice and support in caring for their newborn.
Child-health nurses reflected on having noticed differences among parents from different cultural backgrounds, and their opinion was that women from certain cultures nursed to a greater extent.Breastfeeding was natural for women from some cultures, and it was unusual for them to feed the baby with formula.The nurses thought that this could be related to the differences in resources among countries but also to differences in regard to advice and support from the community and extended families with members of the older generation.

The Importance of having a Consensus Policy
Child-health nurses described that parents expressed that they were given different information depending upon whom they were talking to; they noted that midwives at the maternity ward and child-health nurses gave them different advice.Child-health nurses stated the importance of having a joint breastfeeding policy.However, sometimes it was reasonable to give different advice depending upon the circumstances.It was considered important that the staff from the maternity ward and from the child-health services were unified; otherwise, parents could be confused.The guidelines for breastfeeding were not always followed when support was given.

DISCUSSION
This study describes child-health nurses' experiences of providing breastfeeding support to new mothers.The results show that child-health nurses believe that breastfeeding support in the early stages after birth is important in order to establish breastfeeding.According to Häggkvist et al. [20] the first weeks following childbirth constitute a critical period for establishing successful breastfeeding; during this period, new parents have a great need for support and follow-up.A study [21] shows that nurses experienced that new mothers were in great need of early support, and that their lack of knowledge and support may result in mothers starting infant formula.Andrews [22] emphasized that nurses in child-health care consider their ability to provide early breastfeeding support to be limited; the first home visit could take place up to two weeks after birth.The nurse's main task was to provide advice about breastfeeding techniques and to support parents in creating an atmosphere at home that would promote the success of breastfeeding.It was important to provide early support because there was a risk that mothers might stop breastfeeding before the nurse's first home visit.
The results of this study indicate that child-health nurses thought that early hospital discharge could negatively affect breastfeeding.This corresponds to a Swedish thesis [15] showing that early discharge from the hospital following child birth can have a negative impact on breastfeeding and that a longer stay at the maternity ward contributed to breastfeeding for a longer time.Persson and Dykes [23] argue that a short hospital stay after child birth may mean that parents do not have enough time to receive the support and advice needed to feel confident about breastfeeding their newborn.A positive and supportive attitude from the staff at the maternity ward is known to create a sense of security for the parents.On the contrary, a number of studies [24][25][26] show that breastfeeding is not significantly affected by early hospital discharge.However, other studies [23,[27][28] highlight that the need for professional support was extensive during the first few days at home, regardless of early hospital discharge or longer stay at the maternity ward.
The results also demonstrate that it was the opinion of child-health nurses that a lot of babies were fed with infant formula, and it was common for this feeding method to be introduced at the maternity ward.One study [29] revealed that infant formula was used to a large extent at the maternity ward; almost half of all infants received it as a breast-milk substitute or to extend the amount of breast milk being produced initially.The most common reasons for introducing infant formula were maternal anxiety, particularly the mother's concern about not having enough breast milk, and babies who did not appear to be interested in breastfeeding.According to Chantry et al. [29] the addition of infant formula may increase the risk that the baby will not be breastfed exclusively 30 days after birth as well as the risk of ending breastfeeding after 60 days.A study [20] showed that infant formula was introduced to almost a third of newborns, and the study's authors doubted that there were medical indications for doing so.Ekström, Widström, and Nissen [30] highlight that giving infant formula to newborns with medical indications for doing so did not have any effect on the extent or duration of breastfeeding.Studies have shown that non-medical reasons including the introduction of compensation were commonly used.The most common non-medical reasons for introducing infant formula were that the mother requested that it be added, that the number of times the baby breastfed in a day were too few, and that the infant was too sleepy to breastfeed at night [31,32].Our reflection is that this highlights the importance of having a breastfeeding policy for supporting nursing mothers.
According to these results, child-health nurses describe parents' confidence and their adaptation to the parental role as affecting breastfeeding.Furthermore, according to Hjälmhult and Lomborg [13], mothers may be unprepared to return home after the child's birth, and being able to breastfeed the baby was described as "being real a mother".Furthermore, results show that child-health nurses consider that mothers place too high demand on themselves to succeed with breastfeeding.Similar results were found in a previous study [33] showing that mothers felt that their expectations of breastfeeding were crushed when they wanted to breastfeed but did not succeed.According to O'Brien, Buikstra, Fallon, and Hegney [34], a woman's ability to breastfeed successfully can be affected by psychological factors such as her selfconfidence and her belief that she has enough breast milk for the baby.
The results also demonstrate that child-health nurses believe that breastfeeding is influenced by societal trends.In a study [35], mothers expressed that their attitudes toward breastfeeding were affected by their social network.Mothers thought that breastfeeding limited their opportunities for a social life, and many felt that it was not acceptable to breastfeed in public.In a study [21], both mothers and nurses expressed that bottle feeding has become a norm in today's society.A study [36] shows that support from family and friends are important.Women who had been breastfed and who had parents and friends with positive attitudes toward breastfeeding nursed their babies to a greater extent and for a longer time.Mothers who chose to breastfeed stated that they were a minority and that new parents were affected by others' opinions about breastfeeding.Our results indicate that child-health nurses find that parental equality could affect breastfeeding negatively.Similar results were found by Brown et al. [21], where both nurses and mothers described that the introduction of infant formula meant that mothers were assisted by their partners and thus were able to get more rest or do other things.Using formula was also described as an opportunity for partners and other close family members to participate in the care of the new baby.
The results further indicate that the views about breastfeeding can have cultural differences.A study [10] describes mothers' cultural traditions as affecting breastfeeding.These cultural aspects focused exclusively on ambient opinions and beliefs about breastfeeding, and these could influence breastfeeding either positively or negatively.Our reflection is that support differs according to various cultures; this can be one reason why breastfeeding is perceived to be more evident in certain cultures.This is an unexplored area and requires further research.Also according to the results, child-health nurses consider it to be important to have a consistent message for breastfeeding counseling.Their experience was that new parents receive different advice about breastfeeding from different sources.Bäckström et al. [12] argue that different advice from different healthcare professionals entails increased uncertainty among new mothers, and the authors discusses the importance of organized cooperation between the maternal and child health staff.A study [8] describes that the lack of continuity of care after birth and the lack of support given to new parents are associated with an increased number of healthcare visits during the first two weeks after the child's birth.Studies [8,37], state that breastfeeding-related problems are one of the most common reasons for mothers' needing care during the first weeks after giving birth.One reason for this may be the lack of continuity in the care chain.There is a clear need to support parents in providing breastfeeding counseling.This requires greater resources for effective collaboration between maternity care, maternity ward, and child health.

LIMITATIONS AND STRENGTHS OF THE STUDY
This study has a qualitative research design.Data were collected through focus group interviews with eight nurses working in child-health care who shared their experiences of providing breastfeeding support.Focus group interviews are useful for exploring people's knowledge and experiences, and the group process can help participants to clarify views and issues of importance to them [17].The participants were encouraged to share their views during the interviews to enhance rich descriptions.The use of an interview guide helped to ensure that all participants' views were elicited and recorded.The study results are based on two focus group interviews, and this can be considered a disadvantage, as it may be difficult to see patterns and trends in a small amount of analytical material.The first and the second author analyzed the data, and the results were discussed within the research team, which added rigour to the study.This qualitative study involved a limited number of participants from the same part of the country.The findings can nevertheless be applied to other contexts, especially in similar cultures.In addition, child-health nurses from other contexts can easily relate to the findings because these findings reveal general issues in nursing.

CONCLUSION
The results of this study show that there is a need for improved collaboration between maternal and childhealth nursing staff.Support from child-health care is of great significance in today's society, as many parents do not have support from their families or from a social network.The support must be individually tailored with a focus on the parents' needs, and it is important to take into account current trends in society.Enhanced cooperation between maternal care and child-health care is necessary in order to provide adequate and continuous breastfeeding support throughout the care chain.In addition, further research on breastfeeding support is needed with a combined focus on the experiences of nurses in pediatric care, staff in maternity and new parents.An example might be intervention studies in order to improve the continuity of care chain following birth.Furthermore, it is important that the personnel involved in maternal and child-health services receive clear guidelines and training in effective breastfeeding support and counseling.