Process-oriented training in breastfeeding for health professionals decreases women’s experiences of breastfeeding challenges

Studies show health benefits of breastfeeding for children in developed countries, for both the women and child [1‐3]. If children are breastfed exclusively, for at least three months, the cost of healthcare during their first year of life can be remarkably decreased [4]. The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life. From six months of age, WHO suggests that solids should be introduced as a complement to breast milk, and recommends breastfeeding for two years or longer [5]. Women who want to breastfeed are often motivated to get through breastfeeding difficulties and breastfeed as long as they planned [6]. Women who ended their breastfeeding earlier than they planned often expressed disappointment, sadness and regret over not being able to breastfeed [6]. Further, the women often decide whether to breastfeed or not in late pregnancy. These women often have a negative attitude towards breastfeeding and had low confidence in their ability to breastfeed [7]. The self-confidence is often moderated by the experience of getting support [8]. Support from partner and grandmothers [8, 9] as well as professional support [8, 10] has a positive impact on women’s ability to breastfeed [8‐10]. Lack of professional support has a negative impact on women’s ability to breastfeed [7, 11].

Health professionals have difficulty providing good support when they lack time and evidence-based knowledge and when they have negative attitudes towards breastfeeding. These often result in contradictory breastfeeding advice [12]. Health professionals often give conflicting advice about breastfeeding on demand [13], length and timing of feedings [14], supplementation with infant formula [13, 14], positioning and latching, milk supply [14], and poor weight gain [13]. Professional and individualised support strengthens women’s faith in their own ability to breastfeed [15]. When midwives and nurses receive evidence-based training in breastfeeding, it influences their attitudes, knowledge and clinical skills in a positive way [16, 17], which increases women’s experience of good breastfeeding support [17] during pregnancy and after birthing [18]. In a study from France, mothers who receive breastfeeding support through preventive visits by health professionals in the first postpartum period more often report fewer breastfeeding problems when the baby is four weeks [19]. In their Cochrane review, Renfrew et al. highlighted the importance of context on treatment effects and that non-proactive support was unlikely to be effective [20]. The systematic review also shows that all forms of extra breastfeeding support influence the duration of breastfeeding positively up to six months after birth [20]. Wambach et al. indicated in their summary of 20 years of evidence, that more research is needed to prevent and treat the most common breastfeeding problem reported by women: insufficient breast milk [11]. This problem is one of complexity and crosses international, cultural, and socioeconomic lines [11]. In a study from Australia mothers who have breastfeeding problems within the first four weeks after birth, more often ended exclusive breastfeeding before the baby was six months old, they also have a shorter total duration of breastfeeding [21]. Mothers in several industrialized countries all too often experience breastfeeding problems such as insufficient breast milk production [8, 22‐24], and nipples were sore or cracked [8, 22‐24], in addition health professionals all too often give contradictory advice [24, 25]. When health professionals give contradictory counselling, women often feel confused [26, 27], and frustrated [27]. When breastfeeding does not proceed as women imagine, health professionals’ emotional support is of importance [28]. In a retrospective case control study from Australia mothers who continue to breastfeed despite problems more often experience good support and counselling from health professionals than those women who end breastfeeding earlier than they wanted [25].

The present study was performed in Sweden, in 2000 - 2003. The overall aim was to investigate whether a process-oriented training intervention within the care team of the antenatal (ANC) and child health centers (CHC) would improve maternal perception of support and strengthen maternal feelings for the baby [29]. These results applied to an understanding of how a process-oriented education in support during childbearing and breastfeeding, for antenatal midwives and postnatal nurses, changed the health care professionals’ attitudes in a positive way. The mothers’ perception of support from the professionals and improved the maternal relationship and feelings for the baby were strengthened compared with the control groups receiving traditional care. There was also a positive correlation between preparation for the parental role and a reduced number of infants being given breast milk substitutes without medical reasons during the first week, as well as a delayed introduction of breast milk substitutes after discharge from hospital, if the health professional received the process-oriented education [18, 30‐32]. The aim in this study was to evaluate the effects of a process-oriented training in breastfeeding support counselling for midwives and child health nurses, in relation to women’s satisfaction with breastfeeding counselling, problems with insufficient breast milk, pain or nipple sores in relation to exclusive breastfeeding shorter or longer than 3 months.

The main findings of this study showed that women who received support and counselling from health professionals who had received a process-oriented training in support during breastfeeding increased their ability to succeed with breastfeeding. Women in the intervention group (IG), with exclusive breastfeeding duration < 3 months, were more satisfied with coherent counselling from the health professionals, despite not breastfeeding as long as they planned, compared with women in the control groups. In addition, there were fewer women in the IG with breastfeeding problems such as experienced insufficient breast milk production, compared with women in the control groups.

Many of the women in this study planned their exclusive breastfeeding in line with WHO recommendations about exclusively breastfeeding for six months [5]. In contrast the result of this study showed that women did not always breastfeed as long as they have planned. If the exclusive breastfeeding was shorter than three months they often ended the breastfeeding earlier than they planned, perhaps even before breastfeeding was established. Results from another studies also shows that two-thirds of mothers who intend to exclusively breastfeed are not meeting their intended duration [38].

Our result are 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 women with coherent, evidence-based counselling [39]. Another study shows that when caregivers have communication skills, their ability to empathize and find individual solutions increases, which reduces the risk that women perceive the advice as contradictory [26]. Hence, the health professionals in the IG offered women individualized support, and it resulted in increased confidence in breastfeeding, compared with the women in the control group. Women need to receive realistic, consistent and evidence-based information on breastfeeding during pregnancy [27]. It has been found that women with higher knowledge of breastfeeding have more confidence in their ability to breastfeed [40]. A previously published study from this data set showed that this kind of education for health professionals in support during childbirth and breastfeeding increased women’s experience of professional support during pregnancy and after birth [18]. In addition, the results may be due to the women having better knowledge and more realistic expectations about breastfeeding, which may have increased their confidence in solving breastfeeding problems. Studies show when women have doubts about their own ability to breastfeed, contradictory advice has a more negative impact for them [13, 14]. These results may also affect women’s ability to manage their breastfeeding problems better by themselves, depending on whether the breastfeeding counselling was more suited to the women’s needs and their life situation.

Further, it was found that there were significantly fewer women who experienced insufficient breast milk production in the IG compared with the control groups, for women who had an exclusive breastfeeding duration < 3 months. The reason why these women ended breastfeeding before they planned three days after birth may due to other reasons than those considered in the present study. When professionals are trained in line with the WHO guidelines, the breastfeeding support to women increases, and the women also feel more comfortable in their experience of having enough breast milk production [41]. The results from this study also showed that women who breastfed exclusively ≥ 3 months and experienced insufficient breast milk production were satisfied with their professional counselling, in both the IG and control groups. Women are often unsure about their ability to breastfeed [15], and up to 50% report the perception of insufficient breast milk production [8]. Despite women’s experience of insufficient breast milk production, only about five percent have a biological factor making them unable to produce enough breast milk [7, 8]. Most women who experience insufficient breast milk production provide infant formula, but some women choose to latch the baby on to stimulate the breast or to seek advice from health professionals [42, 43]. Dykes and Williams reported that women with experience of insufficient breast milk were dissatisfied with incorrect and conflicting advice from health professionals, and it had negative consequences for their ability to breastfeed [44]. These results may due to the fact that women in IG who experienced insufficient breast milk production received counselling from health professionals to breastfeed on demand, resulting in stronger self-esteem, or vice versa. When professional breastfeeding support began during pregnancy and continued after birth and when breastfeeding was established, it increased women’s confidence in their ability to breastfeed and solved breastfeeding problems, which led to longer breastfeeding duration. Women with support from health care professionals with the process-oriented training were satisfied with their professional counselling and motivated and able to solve their breastfeeding problems.

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 spill over effects [45]. 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). The 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 spill over 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 spill over effect.

Midwives at antenatal centres need a better understanding about their important role in breastfeeding counselling during women’s pregnancy. This could help women become better prepared for breastfeeding and give them more realistic expectations of breastfeeding. Since many women are worried about not being able to produce enough breast milk, it is important to increase women’s confidence in their ability to breastfeed. Health professionals should emphasize proximity and the relationship between women and their baby and avoid asking questions about sufficient breast milk production. Encouragement is a powerful way to support breastfeeding, and it increases women’s confidence in their ability to breastfeed.

A process-oriented training for health professionals’ support influenced women’s ability to solve breastfeeding problems such as the perception of insufficient breast milk production in a positive way. Women with exclusive breastfeeding duration ≥ 3 months more often had a breastfeeding duration in conformity with their planned breastfeeding duration, compared with women who had a breastfeeding duration < 3 months.