Laid-back breastfeeding: knowledge, attitudes and practices of midwives and student midwives in Ireland

Despite decades of national breastfeeding policies and action plans to improve breastfeeding rates in Ireland, data shows that considerable progress is still needed as Ireland has one of the lowest breastfeeding initiation rates in the world at 63.6%, with exclusive breastfeeding dropping to 37.6% on hospital discharge [1]. Many women that do breastfeed encounter problems, such as sore nipples and babies who have difficulty latching on [2‐5]. This often leads to introduction of formula, a reduction in exclusive breastfeeding on discharge and greater breastfeeding cessation overall [3, 5].

Laid-back breastfeeding (LBBF) is an approach where the mother relaxes into a semi-reclined position with baby resting in full frontal contact, tummy down with the mother’s arms acting as guardrails instead of supporting the weight of the baby. This position enables gravity to provide positional stability for the infant, allowing up to 20 primitive neonatal reflexes to be activated, reflexes which traditional upright breastfeeding positions often inhibit [6]. It requires minimal professional input, instead using mothers’ intuitive breastfeeding skill partnered with innate infant reflex behaviours. Colson suggests that this mother baby partnership potentially empowers mothers to adopt a more active role in their breastfeeding journey [7].

Laid-back breastfeeding is a position more likely to lead to successful breastfeeding [6, 8, 9] and is recommended by many organisations, such as La Leche League International [10], the Association of Lactation Consultants of Ireland, Lactation Consultants of Great Britain, the National Childbirth Trust as well as the Health Service Executive (HSE). It is also recommended in Ireland’s National Paediatric Hospital, Our Lady’s Children’s Hospital Crumlin [11] and as part of the Baby Friendly Initiative (BFI) 20-h Breastfeeding Course [12].

In addition to reducing problems such as sore and cracked nipples and helping the infant to obtain a deeper, more stable latch this approach enables women to practice and attain skills themselves, encouraging breastfeeding self-efficacy rather than health professionals acting as experts positioning babies [13].

Following on from Colson’s seminal research [6] mainstream breastfeeding literature introduced LBBF over a decade ago [10, 14]. It then began to appear in midwifery and lactation journals [15‐17]. A recent randomised control trial [8] showed this position to significantly reduce breast problems such as sore and cracked nipples, engorgement and mastitis by as much as half. A large meta-analysis from 2021 involving almost 2000 mother and infant pairs found similar results [9]. Laid-back breastfeeding is also helpful for babies with breastfeeding challenges, such as tongue-tie or receding lower jaw because gravity pulls the tongue and chin forward [18].

Laid-back breastfeeding also has advantages for midwives, such as saving time and eliminating the need for detailed latching instructions [13, 15]. Further advantages include potentially reducing job-related back, neck, and shoulder pain for health professionals from bending over to assist with breastfeeding [13], which is frequently reported by midwives as causing back pain and discomfort [19]. Midwives working in postures requiring more than five minutes bending at the waist, as in a “hands on” approach to breastfeeding help, are at increased risk of neck and upper back musculoskeletal symptoms [20].

Experts now agree that that LBBF should be the first position to offer when helping establish breastfeeding before other alternative positions are suggested [7, 10, 13]. However, anecdotal evidence suggests that despite these advantages LBBF is not often suggested to mothers and does not appear to be regularly recommended as a breastfeeding position.

Difficulties in initiating and maintaining breastfeeding are complex and multifactorial [21]. Effective breastfeeding support to build maternal confidence and skill is paramount as breastfeeding is being initiated [2, 3]. However, studies show that breastfeeding mothers in Ireland frequently do not feel adequately supported by health professionals [21‐24]. The provision of safe, kind compassionate care, informed by the best available evidence is fundamental to midwifery practice [25]. National policies also emphasise the importance of using evidence based practice [26, 27]. Midwives play an integral role in helping women to initiate and sustain breastfeeding. McGuinness et al. emphasises the importance of midwives in building women’s confidence and ability to breastfeed in the early days as the key to successful breastfeeding [2]. They provide contemporary knowledge and skills enabling women to continue breastfeeding when they are discharged home. Postnatally, mothers require timely and responsive support from health professionals, who ideally have undertaken standardised breastfeeding education [23]. The HSE Breastfeeding Action Plan 2016–2021 [27] recommends continued education and updates for Irish health professionals.

Current knowledge, attitudes, and practices of midwives in Ireland regarding LBBF have not been studied to date. Awareness of midwives’ knowledge and practices in relation to LBBF would provide important organisational information, reinforcing good practice and identifying possible educational needs. Midwifery students’ knowledge and understanding of LBBF would help identify current breastfeeding education, recognising if it is like that of current midwives or if it has developed over time. These findings have the potential to influence breastfeeding education for students and health professionals alike, increasing confidence in their practice and enabling them to empower women in their care and ultimately improve breastfeeding establishment and duration.

The practice of LBBF has yielded consistently positive results [8, 9] yet there appears to be limited knowledge about the practice in Ireland. There is a strong rationale therefore to assess midwives’ and student midwives’ knowledge, attitudes, and practice of LBBF.

Out of a possible sample size of 327 midwives and 293 student midwives, 253 valid responses were received giving an estimated overall response rate of 40.8%. The hard copy response rate for the three main clinical sites was 24.4%, and most successful in the regional units (Unit C, 75% and Unit B, 44% of all midwifery staff). However, larger numbers of responses were received via the online questionnaire (68% of the total responses), especially from student midwives.

This study aimed to discover the current awareness, knowledge, and practices of midwives and student midwives regarding LBBF in Irish hospitals.

Despite high awareness of LBBF (81.4%), application of this position when helping establish breastfeeding was rarely evident in practice, with only 6.8% of midwives and midwifery students using it as their most frequent position to try with mothers. Significantly, almost 40% of midwives and student midwives surveyed have never used this position at all.

Midwifery students expressed a lack of confidence to challenge cultural norms about teaching breastfeeding, especially the current hands-on approach and did not feel comfortable using a different technique than their preceptor. Recent UK research by Spencer [30] found that students experience predominantly negative attitudes about breastfeeding from their preceptors in clinical practice, which would make discussions difficult. Interestingly, more than half of postgraduate students had never heard of LBBF and none of them used it as their “go-to” position, which may indicate a need for reassessment of this part of their breastfeeding education.

For midwives, it was the more newly qualified staff (< 3 years) that had the most awareness of the position (92.3%), which may reflect the increase of teaching/discussion of LBBF in lactation education over the last decade. However, only 5.3% of midwives working on the wards used this position in practice most often. So, despite an even higher awareness of LBBF than the total number of respondents, there is even less practice of it among staff midwives. This may suggest a hesitancy to challenge current practice.

Laid-back breastfeeding was used by most midwives as an alternative to more familiar positions. As LBBF is relatively new in midwifery education [31] respondents are more attuned to what the literature terms as ‘traditional’ positions that mainstream breastfeeding education adopts [15, 32]. Very few midwives suggest LBBF as their first choice, preferring to use it as a reserve for times when other positions are not working or as an addition to upright positions.

The more popular upright breastfeeding positions are more likely to lead to a shallower latch, contributing to problems such as nipple pain [8, 9, 15, 16]. An Australian study involving 653 mother-infant pairs found that mothers who used the cross-cradle hold in particular were four times more likely to experience nipple pain and trauma [33]. In Unit A this was the most frequently used position. The availability of LBBF as an option could potentially help alleviate such common issues.

Education specific to LBBF could provide midwives with an understanding of how and why a laid-back position enables babies’ primitive neonatal reflexes to stimulate breastfeeding and how upright positions can hinder successful breastfeeding [6]. This can address commonly held misconceptions regarding the superiority of upright positions. Enabling a baby driven approach can lead to greater breastfeeding self-efficacy of mothers. Midwives enhancing mothers’ confidence in their own abilities may ultimately be more important to breastfeeding success than the clinical aspects of teaching [13, 34, 35].

Laid-back breastfeeding can address issues encountered with traditional breastfeeding positions used by the majority of respondents (Table 4) which can be tiring and uncomfortable for both mother and midwife [13, 19, 20]. Respondents suggested that lack of equipment, such as stools, chairs and pillows were barriers to using a LBBF position. However, education will highlight that extra equipment is not needed for LBBF. Full frontal contact and positional stability enabled by LBBF uses gravity to secure the infant’s body to the mother’s eliminating the need for props such as cushions, wrap around pillows and footstools to keep the baby at the correct height [6, 13, 15].

It is noteworthy that nearly 45% of respondents were unaware that mothers did not need to be completely reclined to enable LBBF, i.e., that it can be done with the mother’s body only slightly reclined at a 65° angle. The vast majority (over 85%) did not believe it could be done on an upright chair and felt it was a position best suited to a bed or sofa. Less than a third (29%) believed it is a position that could be used in public. There were some misunderstandings about the possibility of using LBBF when mother and baby were fully clothed, reinforcing the belief that LBBF should be reserved for skin-to-skin contact in the labour ward or on the postnatal ward in hospital. Thus, the nuances of LBBF such as the flexibility of the position were not always appreciated, making it difficult for a midwife to promote its use beyond the early days, when a mother was in company or out and about in public.

Over one-third of respondents did not recognise that LBBF has the potential to reduce breast problems, such as sore or cracked nipples, engorgement, and mastitis [6, 8, 9]—main reasons mothers give for early breastfeeding cessation [36, 37]. Greater knowledge about LBBF for midwives therefore has the potential to increase exclusive breastfeeding on discharge. Mothers post Caesarean section or who may have more challenging anatomy could receive more support from midwives who were confident in the knowledge that LBBF is suitable for them and recognise how it can be adapted for their specific situations.

Respondents frequently mentioned concerns about mothers’ anxiety, lack of confidence, hesitation to use a ‘new’ position and lack of awareness around LBBF as barriers to midwives suggesting it. New mothers tend to have heightened anxiety and lack confidence about many aspects of life with a newborn [35, 38] and infant feeding is no exception. With greater knowledge of LBBF midwives would also gain greater confidence in educating mothers about the position and addressing their concerns. This would help midwives to explain to mothers how using a LBBF position has the potential to benefit them and their babies.

Midwives and student midwives with more exposure to LBBF were much more likely to suggest it. This may be through personal experience of breastfeeding in this position, self-directed study from their own reading or attending conference sessions or from working as a lactation consultant. Attending training specifically about LBBF greatly strengthened its practice. Nearly half of all respondents who have not had this training report that they would like to. It is challenging for midwives to have the confidence and knowledge to suggest this position to help establish breastfeeding when the majority (85%) have not had specific education about how and why LBBF position works.

From the response to the open question, participants in this study appeared to rely on their traditional practices of ensuring the baby latches on with professional ‘hands-on’ help rather than supporting the innate abilities of mothers and babies.

There is much research to show that using a hands-on approach, where their breasts are held, is disliked by women [34, 39‐43] and can have negative consequences for breastfeeding. The practice of attaching the infant to the breast with a grip round the infant’s neck/head and a grip around the mother’s breast/nipple can block the infant’s inborn instincts and is suggested as an underlying factor for infants’ difficulties with latching on [44].

Midwives’ traditional hands on approach to breastfeeding has also been found to lead to a pretence of mothers who appear to be coping in order to avoid seeking further help from midwives when it is needed [34, 39]. As midwives can be the key motivators for early and sustained breastfeeding [2] they are pivotal in educating mothers who may have little support once they are discharged [23]. It is vital therefore that midwives are aware of possible discomfort experienced by women when a ‘hands-on’ approach is used and how to ensure that mothers feel comfortable calling on them for further assistance.

Until very recently midwifery education has encouraged teaching mothers to breastfeed in upright positions [45]. Many respondents recognised that reluctance to use LBBF stemmed from these historic cultural teaching practices which rely on teaching methods based on formula feeding [32]. The seminal textbook for midwifery for over 60 years, Myles Textbook for Midwives [31] has for the first time included LBBF in its latest 2020 edition. This is alongside the more familiar upright positions, which it refers to as “classical breastfeeding positions” [46]. Respondents in this study were candid in admitting that it is hard to break old habits and felt more comfortable to continue to use the same techniques.

For midwives who are used to positions that emphasise health professionals as experts positioning babies, helping to place the breast into the baby’s mouth, the prone position of the baby using gravity to latch on in a LBBF position may seem counterintuitive. Education on the safety of the mother’s breastfeeding position, ensuring positional stability for the infant, and understanding primitive neonatal reflexes is vital in addressing concerns raised by midwives.

The influence of specific education for midwives on using a LBBF position for mothers and babies is further highlighted when reviewing the data (see Additional file 2).

Midwives and student midwives who had specific training about LBBF demonstrated more knowledge and reported more success in helping mothers and babies to breastfeed. Education about LBBF nearly doubled the reported confidence levels for midwives and students. The results of this study clearly show that education significantly enhanced both confidence and adoption of LBBF in practice.

Over the last decade in Ireland, rising childbirth interventions and caesarean section rates [1] have hugely increased the workload of the postnatal midwife [47]. Combined with understaffing and early discharge, these factors contribute to difficulties establishing breastfeeding [22, 48, 49]. Staffing issues in midwifery, heavy caseloads and lack of time to spend with women in the postnatal period are widely acknowledged [22, 34, 50, 51]. These were all issues which respondents in this study identified as barriers to helping women breastfeed.

Considering the ‘hands-off’ nature of a LBBF position, lack of detailed instructions needed and fewer breastfeeding problems when using this position, greater use of LBBF has the potential to reduce midwives’ workload. Encouraging LBBF empowers women to rely on their own skills, fostering increased confidence and autonomy while reducing the need for professional assistance. Any intervention that helps initiate and sustain breastfeeding is a priority for researchers, midwives, and policy makers [26, 27].

This is the first study carried out in the Republic of Ireland to explore midwives’ and student midwives’ knowledge, attitudes, and practices of using a LBBF position. The findings point to a high awareness of LBBF, but very low use of the position in practice. It also highlights the challenges of implementing LBBF effectively in hospital settings. The study emphasises the significance of additional education about the physiological foundations of LBBF for both undergraduate and ongoing midwifery training to increase its use in practice.

Improving breastfeeding initiation and duration in Ireland is a multifactorial and complex issue. While LBBF may not be a ‘catch-all’ remedy for every breastfeeding situation, experts agree that it should be the first position to offer before other alternative positions. Enhancing midwives’ understanding regarding LBBF could help alleviate any apprehensions about adopting a more ‘hands-off’ approach, using LBBF as a primary option for women rather than a ‘fall back’ one. Although this study was specific to Ireland, it may also have relevance worldwide to cultures that continue to promote “hands on” breastfeeding for health care professionals assisting mothers in establishing breastfeeding.