Background
Methods
Setting
Participants
Site | Level of health institution | Position of healthcare providers | No. of in-depth interviews | No. of focus group discussions | No. of focus group discussions participants | Total |
---|---|---|---|---|---|---|
Datong | County | Obstetrician-gynecologist | 3 | 0 | 0 | 3 |
Nurse | 1 | 0 | 0 | 1 | ||
Midwife | 0 | 1 | 3 | 3 | ||
Township | Obstetrician | 1 | 0 | 0 | 1 | |
Village | Village doctor | 4 | 0 | 0 | 4 | |
Village MCH worker | 2 | 2 | 3/6 | 11 | ||
Yanchi | County | Obstetrician | 4 | 0 | 0 | 4 |
Nurse | 1 | 0 | 0 | 1 | ||
Township | Obstetrician | 1 | 1(mix with obstetricians and township MCH workers) | 2 | 3 | |
Township MCH worker | 1 | 1 | 2 | |||
Village | Village doctor | 3 | 1 | 5 | 8 | |
Total | 21 | 5 | 20 | 41 |
Data collection procedures
Data analysis
Results
Characteristics of the participants
Variable | County | Township | Village | ||
---|---|---|---|---|---|
Age (Median(interquartile range)) | 43.5 (32.3,48.8) | 40 (24.8,48.5) | 45 (27,53) | ||
Education | General education | Below high school | 0 | 0 | 8 |
High school | 0 | 0 | 1 | ||
College | 0 | 1 | 0 | ||
Professional training | Technical school | 3 | 4 | 11 | |
Junior medical college | 1 | 1 | 2 | ||
Medical college | 8 | 0 | 1 | ||
Gender | Female | 12 | 5 | 15 | |
Male | 0 | 1 | 8 | ||
Position | Obstetrician-gynecologist | 7 | 4 | 0 | |
Midwife | 3 | 0 | 0 | ||
Nurse | 2 | 0 | 0 | ||
Village doctor | 0 | 0 | 12 | ||
Township MCH worker | 0 | 2 | 0 | ||
Village MCH worker | 0 | 0 | 11 | ||
Years in position (Median (interquartile range)) | 13.5 (6.3,25.5) | 14 (1.8,22) | 10 (4,21.5) |
HCP’s perceived barriers to providing breastfeeding support
Themes | Subthemes |
---|---|
(1) Lack of medical resources | Inadequate staffing Lack of financial incentives |
(2) Lack of clear and specific responsibility assignment | No one takes the lead Mutual buck-passing |
(3) HCP’s lack of relevant expertise | Lack of knowledge and skills Low prestige of village HCPs |
(4) Difficulties in accessing mothers | Medical equipment shortages reduce services utilisation Mothers’ housing situation Mothers’ mobility Cultural barriers |
Lack of medical resources
Inadequate staffing
We don’t have enough doctors, midwives, and nurses. There are often three- or four-women giving birth simultaneously (in the delivery rooms), with only two midwives on duty. The midwives need to pay attention to priorities such as whether the mother is hemorrhaging or the newborn is suffocating. So, many other details such as delayed cord clamping, early skin contact, and early initiation of breastfeeding cannot be implemented. (obstetrician, county-level)
There are about 70 pregnant women registered to be seen in one morning. The time allocated to each patient is so limited that I have no extra time to provide breastfeeding support. I will pay attention to these details if I have spare time.
I haven’t finished primary school and can hardly read, it’s hard for me to provide professional health services for mothers. (village doctor)
Lack of financial incentives
It (breastfeeding support) takes a lot of time and does not make any profit, we do it for free!
Village doctors are farmers. They are paid very low wages and are not provided with any of the five social benefits mandated by the Chinese Government (including a pension, health insurance, unemployment insurance, occupational injury insurance, and housing funds). (obstetrician, township-level)
They also raise cattle or run a business to earn money to support their families. Some village doctors have quit their jobs because of the low wages for their medical services. There is a shortage of village doctors, and the quality of MCH service is still a big concern in the village. (obstetrician, township-level)
Lack of clear and specific responsibility assignment
No one takes the lead
The problem is that nobody takes the lead in providing breastfeeding support across the entire care continuum. We just do what we can do. (nurse, county-level)
Our leaders do not know what efforts need to be taken to promote breastfeeding, nor do they realise how hard it is. Actually, we have many challenges, but they do not care. Much detailed work (to promote breastfeeding) cannot be carried out. (nurse, county-level)
Mutual buck-passing
Many women take prenatal checkups in the county hospital outpatient service. If someone gives them breastfeeding guidance, then it will be easier for us when the mothers are hospitalised for giving birth. (nurse, county-level)
For mothers with clogged milk ducts, if we have enough time, we may help them, otherwise we can’t. But this is also the responsibility of nurses. (obstetrician, county-level)
Women are always in the third trimester when they come here. Township and village HCPs have more time and opportunities to communicate with mothers. They should do a good job of breastfeeding support. (obstetrician, county-level)
There was a mother who had breast pain and could not feed the baby. I did not know how to help her, so I told her to go to the county hospital for treatment. (village doctor)
HCP’s lack of relevant expertise
Lack of knowledge and skills
Anyway, I do not approve of breastfeeding when mothers got mastitis because the quality of breast milk is not good for baby feeding.
We never participated in breastfeeding-related training. Breastfeeding knowledge and skills are rarely involved in our re-educational trainings. (obstetrician, county-level)
I received training before. The trainers taught too much and too fast. Now, I can hardly remember what I have learned, and I never used those in my practice. (village MCH worker)
Low prestige of village HCPs
I don’t know much about breastfeeding. When I saw relevant information on the internet, I forwarded it to the Wechat group chat. But I guess they didn’t pay attention to these messages at all. No one ever asked me any question.
Difficulties in accessing mothers
Medical equipment shortages reduce services utilisation
We can only cope with basic examinations such as blood pressure, fetal heart rate, and B-ultrasound, so we usually tell them to go to the county hospitals to do other tests. Mothers also need to go to the provincial hospitals to do four-dimensional color Doppler ultrasounds and Down’s syndrome screening because the county hospitals don’t have the equipment. (obstetrician, township-level)
Mothers’ housing situation
The villagers’ residences are very remote and dispersed. Some even live in the mountains. I need to ride 15 km to get to the farthest family. When it rains, I have to walk for half the distance. (village doctor)
If there is a watchdog waiting for me at the gate, that’s big trouble. The first thing to do after getting off the motorcycle is to find something to fight with the dog. (village doctor)
The most difficult thing for me is the watchdog. I usually spend one or half an hour getting to the mother’s home but dare not get in because of the watchdog. (village MCH worker)
Mothers’ mobility
Mothers have to work in big cities even if they are pregnant. When they come back, they are about to give birth. Their prenatal checkups are not done here. That is troublesome for us (obstetrician, township-level).
Most mothers are not at home. I seldomly know them and have never met some of them. We communicate through the cell phone (village doctor).
Cultural barriers
When I went for postpartum visits, the mothers and babies always stayed in a room, and they would not let me in for fear that their babies would cry (village MCH worker).
They do not like others to look at their bodies. They said that their body would be dirty after taking prenatal checkups (obstetrician, township-level).