Background
To become parents for the first time is a major change of life event [
1,
2]. It involves the physiological endeavour of pregnancy, birth and breast-feeding, but also changes in social lives [
3,
4]. To handle these challenges mothers need both social and professional support [
5,
6]. Support has been described as an interactive process that affects wellbeing and health of the individual [
7]. Social support is offered within individuals own network and then working relationships and trust is required for support to be effective. Professional support, however, is directly available but limited by professional domain and knowledge, for example childbearing and midwifery [
8]. So it is important to differentiate between social and professional support in research [
9]. Care interventions with professional support should also aim to strengthen social support [
10]. In childbearing, professional support from nurses and midwives is important for parents’ childbirth experience [
11‐
14]; for mother infant interaction [
15‐
17] and for breastfeeding [
18]. Health professionals’ personal attitudes affect quality of care and support as well as their perception of the support they offer. This will affect professionals ability to meet patients’ individual needs, however more research is needed [
19]. So to achieve improved quality of care, a change of attitude among health care professionals is needed. To change attitudes an approach with both fact and reflection has been described [
20] and reflection is essential for professionals’ skills development [
20,
21]. Therefore an intervention with a process-oriented training including evidence based lectures and reflection was performed to change health professionals’ attitudes toward breastfeeding and parental support. This intervention resulted in health professionals attitudes becoming more facilitating and less regulating [
22], mothers experienced improved professional support, improved self-reported relation to and feelings for the baby and breastfeeding [
15,
17,
23‐
28]. Due to these positive results there is a need to illuminate the methodological approach further. The overall aim is therefore to describe a methodological approach to improve and evaluate health care professionals’ attitudes toward breastfeeding and parental support in order to improve quality of care in childbearing.
Discussion
This article describes a methodological approach, a process-oriented training, which improved midwives and child health nurses attitudes toward breastfeeding and parental support. Improved attitudes in health professionals lead to mothers being more satisfied with professional support. In addition the improved professional support increased mothers feelings and relation to the baby, earlier initiation and higher frequency of breast-feeding the first 24 h, less breast-milk substitute (without medical reasons), less breast-feeding challenge (despite the use of nipple shields) and as a result of these, longer breastfeeding duration.
These improved attitudes in health professionals tended to be stable over time and IG mothers reported more satisfaction with emotional and informative professional support during the first nine months after birth than CG mothers. In line with other research, quality of care is improved by enhancing health professionals’ attitudes [
34]. since health professionals attitudes influence their ability to meet individual needs of patients [
21,
35]. In order to improve attitudes both fact and reflection is needed [
20] which is essential for skills development in professional education [
20,
21]. This is in line with our result that a process-oriented training which integrated facts with reflections on both professional and personal level lead to improved professional attitudes.
In evaluation of the process-oriented training, health professionals described that they did not have adequate time available to pursue the education during working hours. They described that despite decision making heads expressed an interest in the training the health professionals experienced that they did not have reasonable conditions to pursue the course (unpublished data). This points to lack of understanding among heads of organizations that competent health professionals require reasonable conditions to develop good quality in health care [
36]. Evidence based health care demand possibilities for health professionals to develop their abilities and knowledge during working hours. Heads of health care should not assume that midwives and nurses shall dedicate their free time for professional development.
IG mothers reported a more positive perception of professional support during childbearing as a result of the intervention. However, our results also highlight the fact that IG mothers reported more positive support from the professionals in the delivery ward and the maternity ward, despite the fact that these health professionals were not involved in the process-oriented training. Social and professional support is affected by earlier experiences of receiving support [
7,
37], and positive memories of a situation influence a friendly approach in a similar situation [
38]. It is possible that mothers who have had a more positive experience of support during antenatal care are more likely to have a positive perception of support from other health professionals as well. Mothers in the IG also reported improved professional support in preparation for the parental role and their partners were more active in parental support groups compared to CG mothers. This result is in line with other researchers that highlights professional support as important for parent’s childbirth experience [
11‐
14].
In addition results from our studies showed that improved professional support increased IG mother’s feeling and relation to the baby, including IG mothers with caesarean birth who are particularly vulnerable. Mothers with caesarean birth are more likely to suffer from psychosocial health problems after childbirth [
39‐
41], and they seem more self-oriented and less self-confident when caring for the baby two months after birth [
40], which may negatively influence mother-infant interaction [
42,
43]. These results point to the importance of improving professional attitudes to improve support and quality of care for mothers and families in childbirth.
As a result of the process-oriented training mothers in the IG reported earlier initiation, higher frequency of breast-feeding the first 24 h [
25], less breast-milk substitute (without medical reasons) [
26], less breast-feeding challenge despite the use of nipple shields and as a result of these increased breastfeeding duration [
24] compared to CG mothers. Our result is in line with other research showing that when health professionals receive breastfeeding education based on WHO guidelines, they feel more secure and experience an increased ability to support mothers with coherent, evidence-based counselling [
44]. Other research shows that when caregivers have communication skills, their ability to empathize and find individual solutions increases, which reduces the risk that mothers perceive the advice as contradictory [
45‐
47]. Mothers need to receive realistic, consistent and evidence-based information on breastfeeding [
48] and a combination of group and individual counselling is more efficient for breast-feeding success [
49]. Mothers with higher knowledge of breastfeeding also have more confidence in their ability to breastfeed [
50].These results may affect mother’s ability to manage their breastfeeding problems better, depending on whether the breastfeeding counselling was more suited to their needs and their life situation.
This longitudinal intervention method with two control groups (CGA data was collected before any effects of the intervention could be measured) was selected as being suitable for the study. This is a design suggested to measure possible spillover effects [
51]. More differences were found when the IG was compared with the CGA than when the IG was compared with the CGB (where data were collected simultaneously with the IG). These results show that changes also take place among controls when an intervention is being rolled out. In the professional network of midwives and child health nurses, knowledge and information are shared, which easily leads to spillover effects between intervention and control professionals. These results thus demonstrate the value of using a historic control group, which will provide a baseline against which to evaluate the spillover effect. Strength of the study was that the participating mothers did not know whether they encountered health professionals who had undergone the process-oriented training or not.
Acknowledgements
This study was supported by the Skaraborg Institute for Research and Development; the School of Health and Education of the University of Skövde; the Primary Care Unit in Skaraborg and the Science Committee, Central Hospital, Skövde; the Strategic Research Programme in Care Sciences and the Board of Research for Health and Caring Sciences, Swedish Research Council, grant nos. K1999-27P-13085-01A and K2001-27P-13085-036, Eva Nissen.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
According to ICMJE guidelines, AE have made substantial contributions to conception and design, and acquisition of data analysis and interpretation of data. ST have made acquisition of some of the data analysis and interpretation of data. AE and ST have drafting the manuscript and have given final approval of the version to be published.