Learning the HardWay: Expectations andExperiences of Infant Feeding Support

Maggie Redshaw, BA (Hons), PhD, and Jane Henderson, BSc (Hons), MSc

ABSTRACT: Background: Breastfeeding involves learning for women and their infants.For emotional, social, and developmental reasons this type of feeding is recommended for allnewborn infants but for those in exceptional circumstances. The objective of this study was togain a better understanding of what is needed in the early days to enable women to initiate andcontinue breastfeeding their infants. Methods: Data from a large-scale national survey ofwomens experience of maternity care in England were analyzed using qualitative methods,focusing on the feeding-related responses. Results: A total of 2,966 women responded to thesurvey (62.7% response rate), 2,054 of whom wrote open text responses, 534 relating to infantfeeding. The main themes identified were the mismatch between womens expectations andexperiences and emotional reactions at this time, staff behavior and attitudes, and theorganization of care and facilities. Subthemes related to seeking help, conflicting advice,pressure to breastfeed, the nature of interactions with staff, and a lack of respect for womenschoices, wishes, previous experience, and knowledge. Conclusions: Many women who suc-ceeded felt that they had learned the hard way and some of those who did not, felt they wereperceived as bad mothers and women who had in some way failed at one of the earliesttasks of motherhood. What women perceived to be staff perceptions affected how they sawthemselves and what they took away from their early experience of infant feeding. (BIRTH 39:1March 2012)

Key words: breastfeeding, midwifery, postnatal support

Breastfeeding promotion is a high priority for public

health, and exclusive breastfeeding for 6 months, with

supplemental breastfeeding to 2 years of age, is recom-

mended (1,2). However, patterns of infant feeding are

variable, even within developed country contexts. In the

2005 Infant Feeding Survey in England, initial breast-

feeding occurred following 78 percent of births, but by

6 weeks this proportion had declined to 48 percent, and

at 6 months only a quarter of mothers gave any breast-

milk. In 2007 a similar proportion of women in England

(80%) reported putting the baby to the breast at least

once, and three-fourths (75%) breastfed or partially

breastfed their infants for the first few days after birth

(3). A similar proportion of mothers (70%) in a 2006

United States survey were exclusively or partially

breastfeeding at 1 week, and at 4 to 6 months this pro-

portion had also reduced to 20 percent (4). Data from

Canada collected over the same time period indicate

higher rates of initial breastfeeding (90%), just over half

of mothers (52%) doing so at 3 months and 14 percent

at 6 months, although more than half were still giving

some breastmilk (54%) at this time (5).

Breastfeeding support has commonly been seen as an

integral part of postnatal care, and women often report

Maggie Redshaw is a Senior Research Fellow and Social Scientist andJane Henderson is a Health Service Researcher at the Maternal Healthand Care Research Unit, National Perinatal Epidemiology Unit,Oxford, United Kingdom.

The Maternal Health and Care Research Unit within the NationalPerinatal Epidemiology Unit (NPEU) is funded by the Department ofHealth in England. The views expressed are those of the authors anddo not necessarily reflect those of the Department of Health. The origi-nal survey was funded by the Department of Health (London, UK), theCare Quality Commission (formerly Healthcare Commission; London,UK), and the NHS Information Centre (London, UK).

Address correspondence to Maggie Redshaw, BA (Hons), PhD,National Perinatal Epidemiology Unit, University of Oxford, OldRoad, Oxford OX3 7LF, UK.

Accepted August 4, 2011

2012, Copyright the AuthorsJournal compilation 2012, Wiley Periodicals, Inc.

BIRTH 39:1 March 2012 21

needing information and feeling unsupported at this

time, frequently discontinuing breastfeeding earlier than

they would have wished (4,68). Early on, the reasons

most commonly given for stopping breastfeeding are

insufficient milk, painful breasts or nipples, and the baby

not sucking or rejecting the breast (9). In the second

week, women were also more likely to report that this

type of infant feeding took too long or was too tiring.

Using womens own words, the aim was to better under-

stand their experience of postnatal care and support in

relation to breastfeeding, by identifying predominant

themes and reflecting on the language and constructs

used.

Methods

In a national survey of womens experience of maternity

care in England, a random sample of women who gave

birth in a week in March 2006 were selected by the

Office for National Statistics (ONS) and surveyed at

3 months after the birth (8). Structured question

response formats and some open questions were used.

Reminders were sent to nonrespondents at 2 weeks and

a further questionnaire at 4 weeks. Multi-centre

Research Ethics (MREC) approval was obtained before

the study.

Quantitative data from the survey are used to

describe the women responding and the open text

responses to two open questions used in this qualitative

analysis. The same questions, which also were used in

an earlier survey (10), were: If there was anything

about your postnatal care in hospital that you could

change, what would it be? and Is there anything

else you would like to tell us about your care while

you were pregnant or since you have had your baby?

All feeding-related responses were included in the

analysis.

In the process of qualitative analysis the responses

were read and reread separately by two researchers,

anticipated and emergent themes were identified, and

differences in interpretation were discussed (11). Ini-

tially, after reading all the responses, each was coded

under an overarching theme, and by subthemes that had

been identified and agreed upon. For the purposes of

numerical analysis, up to three predominant themes

were coded for each response. Codes were refined fur-

ther as the analysis progressed in an iterative manner,

and discrepant cases were sought to illuminate the issues

(1214). In rereading the responses, new associations

were made among different facets of the analysis. The

quotations selected and discussed illustrate the themes

arising from the experience of early infant feeding and

support.

Results

The response rate to the survey was 62.7 percent repre-

senting 2,966 women. The mean age of the infants at the

time of questionnaire return was 15.5 weeks (median:

15, range: 1328 wk). Using data from the ONS sam-

pling frame, it was possible to compare responders and

nonresponders. Compared with responders, nonrespond-

ers were more likely to live in London, be single parents,

born outside the United Kingdom, be younger, live in a

deprived area, be a student, or not state their occupation

(8).

Eighty percent of women reported putting their baby

to the breast at least once. In the first few days 59 per-

cent of women gave breastmilk only, 16 percent breast-

milk and formula, and 25 percent formula only. At the

time of the survey 26 percent of women gave breast-

milk only, 17 percent breastmilk and formula, and 57

percent formula only (15). Those who responded to the

open questions were slightly more likely to be first-

time mothers, to be white, have left school after

16 years, be older, and live in more advantaged areas

(Table 1).

A total of 1,436 women (48.4%) wrote text responses

about postnatal hospital care, 254 of which (18%)

referred to one or more aspects of infant feeding, and

1,172 women responded to the Anything else you

would like to tell us question, of whom responses from

17 percent (196) related to infant feeding. The analysis

is based on these data.

Table 2 provides an overview of womens responses,

showing four broad themes, which predominantly

related to matching experiences with expectations,

staff behavior and attitudes, emotional reactions,

and the organization of care and facilities. Subthemes

related to seeking help; conflicting advice; pressure to

breastfeed; interactions with staff; and a lack of respect

for womens choices, wishes, previous experience, and

knowledge. The themes raised in response to both ques-

tions were similar and are discussed in the text.

Matching Experiences with Expectations

Expectations in relation to infant feeding support were

clearly articulated. Women described needing active

help, consistent advice and information, and care for

themselves: they both needed and expected more help

with feeding, especially breastfeeding, which involved

advice and practical help:

I am breastfeeding my now 4-month-old daughter, but nearly

gave up due to no one giving me the time to sit down andshow me what to do. (1688)

22 BIRTH 39:1 March 2012

Breastfeeding needs to be established before mothers aredischarged to be observed and advice and guidance given.Hospital walls were plastered with the benefits of breastfeeding

but nobody actually talked about it. (1988)

Some women felt undermined when they had diffi-

culty with breastfeeding:

After my c-section, I struggled with feeding my baby during the

night because I found it hard to sit up and was exhausted and in

discomfort. I was not given much support I felt a bit of a nui-sance and it was intimated I should give bottle feeds. I may have

started bottle feeding if this had been my first child. (5061)

Others reflected on their lack of experience and how

they were helped with feeding:

Every midwife had a different way of helping to breastfeed

which was very confusing. (5453)

My baby was sleeping most of the day it was my first childI was unsure what to do. I asked one midwife if I should

waken the baby to feed and she said no . My babywas awake all night feeding and the midwife on night

shift said I should have been feeding the baby during the day.

(1486)

Table 1. Summary of Maternal and Infant Characteristics for Survey Respondents

Characteristics

Women Respondingto Open Question on

Postnatal Stay (n = 1,436)No. (%)

Women Respondingto Open Question on

Anything Else (n = 1,172)No. (%)

Women NotResponding to OpenQuestions (n = 902)

No. (%)

MaternalAge (yr)1619 54 (3.8) 38 (2.5) 45 (5.1)

2024 193 (13.5) 191 (12.4) 176 (19.8)

2529 349 (24.5) 347 (22.5) 226 (25.4)

3034 470 (33.0) 542 (35.2) 269 (30.2)

3539 300 (21.0) 352 (22.8) 158 (17.8)

40+ 60 (4.2) 71 (4.6) 16 (1.8)

Age on leaving full-time education

Contradictory advice about positioning and attach-

ment were more common when women were having

problems and had seen several midwives:

To be seen by one or as few people as possible to help with

breastfeeding. Every time I pressed my buzzer for help, a

different person came and told me a different way to feed my

baby, I got so confused and upset. (2228)

Advice about breastfeedingmy son and I struggled with feed-

ing . Each change of shift saw different advice, I found thisvery distressing. (2751)

First-time mothers expected to receive extra help with

feeding and general baby care:

Being a first time mum I would have liked to have been shown

how to breastfeed properly. There werent enough staff and I

was left for hours, when I was told they would be right back.

(6012)

The midwives were too quick to judge my latch-on technique

and I did not realise that my breastmilk had not come I wasexhausted and felt alone as soon as my husband left. (4849)

Conversely, multiparous women were expected to

know how to care for their baby and some felt

neglected:

As I was a second-time-around mother I was left alone. No one

checked if I was coping or all right with feeding. (4687)

Staff should have more time to spend with new mothers, help-

ing with feeding Although this was my second baby, itwould have been reassuring to have refreshers I was left tomy own devices. (3893)

Mothers of babies born preterm or at low birthweight,

or with tongue-tie or jaundice also expected to get extra

help with feeding and infant care. If the baby was in the

neonatal unit, some women had to split their time

between the postnatal ward and neonatal unit:

I had a caesarean and my baby went to SCBU [neonatal unit]

for 4 days. I felt lost as I had to keep walking between

SCBU and the ward to breastfeed 3 hourly I missed mealsand drug rounds. (5844)

Several women wrote about how breastfeeding was

dealt with in antenatal classes. Although it was useful to

have information about the benefits of breastfeeding,

some felt it led to expectations that might not be

realized:

I feel the information on breastfeeding is unrealistic. Although

I know you want to encourage breastfeeding, the info should be

more truthful, i.e., it hurts and takes a long time to establish a

good feeding technique. It was very easy for the mid-

wives health visitor to blame incorrect positioning but I gotmastitis twice and engorgement and I felt very alone. We are

fine now, but the leaflets and books show pictures that look so

lovely and idealistic. (2504)

Staff Attitudes and Behavior

Although some women described very positive experi-

ences with staff, a principal area of conflict related to

Table 2. Overarching Themes from Open Text ResponsesRelating to Infant Feeding in the Context of MaternityCare. Number of Responses (% of Respondents whoResponded on Infant Feeding Issues)

Themes

PostnatalHospital Care

Anything Elseabout Care

No. (%) No. (%)

Womens needs and

expectations

Help and support 152 (29.5) 118 (37.8)

Consistent advice 41 (8) 27 (8.7)

Information 29 (5.6) 19 (6.1)

Care for the women

themselves

20 (3.9) 5 (1.6)

Care for their baby 8 (1.6) 3 (1.0)

Milk supply 7 (1.4) 13 (4.2)

Theme totals 257 (50) 185 (59.4)

Staff behavior and attitudes

Expectation women

will breastfeed

18 (3.5) 19 (6.1)

Expectation women

will look after their

own babies

13 (2.5) 3 (1.0)

Wishes, choices, and

knowledge respected

18 (3.5) 20 (6.5)

Pressure to breastfeed 25 (4.8) 24 (7.7)

Institutional rules 6 (1.2) 4 (1.3)

Attitudes and language 35 (6.8) 10 (3.2)

Physical intervention 7 (1.4) 1 (0.3)

Theme totals 122 (23.7) 81 (26.1)

Womens emotional reactions

Anxiety and worry 21 (4.1) 10 (3.2)

Engaging in a struggle 4 (0.8) 9 (2.9)

Feeling guilty 7 (1.4) 11 (3.5)

Loneliness and isolation 18 (3.5) 2 (0.6)

Theme totals 50 (9.8) 32 (10.2)

Organization of care and

facilities

Privacy 8 (1.6) 1 (0.3)

Nutrition and meals 13 (2.5) 3 (1.0)

Staffing 33 (6.4) 2 (0.6)

Length of stay 16 (3.1) 2 (0.6)

Neonatal and

transitional care

8 (1.6) 3 (1.0)

Equipment and facilities 8 (1.6) 3 (1.0)

Theme totals 86 (16.8) 14 (4.5)

Overall totals 515 (100.0) 312 (100.0)

Overall totals are greater than the number of respondents becausesome womens responses were categorized under several differentthemes.

24 BIRTH 39:1 March 2012

breastfeeding versus bottle feeding. Most had decided to

try breastfeeding, but if they had difficulties and would

have opted to give a bottle, felt under pressure:

Breastfeeding was pushed on me. I had chosen to feed this way,

but found it very difficult. It took 2 days to get a bottle for my

baby and I felt very bullied into continuing breastfeeding even

when it was not working. (5736)

Some women felt it was not a matter of choice and

wanted their position to be understood:

I struggled a great deal . not every mother decides she wontbreastfeed for convenience. I was desperate to breastfeed but

had huge problems. (2606)

Being someone that was determined to have a natural birth and

breastfeed, an emergency CS was a shock . I found the pres-sure to breastfeed after my baby had been given a bottle on her

first night in SCBU was intense. (3282)

Although I have managed to successfully breastfeed I feltthat breastfeeding was almost an obsession with virtually every

health care professional I came into contact with I feltunable to ask for advice because the approach seems to be to

keep women breastfeeding at all costsregardless of pain, dis-

comfort, fatigue, etc.and all the guidance and support is

geared towards an ideological push for breastfeeding rather

than the wellbeing of the mother. (5121)

Staff had different attitudes and approaches, and some

women reported being made to feel guilty or inadequateif their baby did not breastfeed well, or if they chose to

give formula. They would have liked help with formula

feeding and felt neglected compared with breastfeeding

mothers:

The midwives couldve been more supportive towards me

because my baby didnt want to breastfeed. I was made to feel

that it was my fault and was subsequently ignored. (1637)

They made me feel very guilty for being unable to do it. (3075)

Finding that staff did not always support breastfeed-

ing came as a surprise to some women:

I had trouble starting breastfeeding, I asked a midwife to help

me but she just told me to use a bottle! (6666)

Women reported that midwives expected them to ask

for help when needed. However, they commonly felt

that breastfeeding support should be offered rather than

having to ask:

Staff were very busy, not enough time to check if (especially

first-time mums) doing OKjust pop in and ask if all OK and

take your word for it. I had not slept in 3 days and was not cop-

ing but said I was OK and was left alone. Felt I did not get any

help or support postnatallyespecially breastfeeding. (4463)

Nobody seemed to have the time to sit and help me to get my

baby to latch-on or to explain how it works. (4736)

Midwives differed from the women in their care in

the importance they attached to privacy. In multiple

occupancy areas midwives preferred to have curtains or

screens open to encourage women to look out for each

other and be sociable, but some women wished to feed

in private and explained that curtains were opened

without their permission:

Told me they preferred curtains open in the morningmidwife

opened without permission. I wanted to breastfeed in private

and to check I hadnt leaked any blood whilst in bed. There

were a lot of male partners and siblings on the ward at this

point. It was a bit off-putting. (1593)

Some women expressed their wishes on this point:

[I wanted] privacy and respect from staff, I am a nervous new

mum, and would preferred to have curtains closed round my

cubicle in the ward, but theyd walk in and leave them open for

the rest of the people on the ward to see!! (4736)

Naughty Children and Bad Mothers

Some of the quotations presented demonstrate the judg-

mental attitudes of staff as perceived by women

responding about infant feeding. Negative staff attitudes

or behavior ranged from women feeling bullied or

judged, being shouted at, midwives acting in a

condescending manner, being insensitive,

inconsiderate, disrespectful, and rude.

No one offered to show me how to breastfeed, bath or change

my baby, and I was shouted at for falling asleep and not feeding

the baby although he hadnt woken up either. (1599)

Some women reported being spoken to like naughty

children when they had tried to breastfeed and failed,

being reprimanded for not doing what was expected:

I made the choice not to breastfeed my baby as my attempts at

feeding my first child were unsuccessful . I was made to feel(by some midwives) like I was a bad mother and felt that Ihad somehow failed... . Is there a reason why we are made to

feel an inferior mother for making the choice to bottle feed ?I was most upset that I couldnt feed my own child and felt that

I needed support, not criticism. I still feel like I havent given

my children the best start in life and feel like I lack something

as a mother. (3026)

Midwives and other staff could be perceived as pow-

erful and authoritative individuals who were in control,

but not always kind or supportive:

I felt very isolated and lonely, and having a private room would

have liked my husband to be able to stay the night with me but

this was not allowed I was kept in for 2 days because I was

BIRTH 39:1 March 2012 25

having trouble breastfeeding, but inconsistency of advice and a

mean school teacher approach from some midwives made

this a horrible experience. (5121)

The infantilization suggested by the language used in

these responses is reinforced by womens reports of hav-

ing to ask about basics such as the location of the toilet,

mealtimes, and the rules about visiting hours and part-

ners staying:

I was just left, when I went onto my ward I didnt have any-

thing explained to me, I was just took to my bed by my midwife

and left, the other girls on my ward explained everything . Itwas little things like where the showers and toilets were, and

where I got the milk from to feed my baby. (1565)

Some women reported feeling that they did not count,

they were just another new mum or a number, not a

person. As in the area of privacy, their wishes were not

always respected and personal space was invaded:

Night midwives were not very goodI had trouble breastfeed-

ing, and they were very rough and fairly unhelpful when I asked

for help. (3349)

I had been breastfeeding my baby. she said he was notlatched on and grabbed my breast and pushed it into his mouth.

This was highly inappropriate and insensitive he had fedsuccessfully for 1 2 hour, but she refused to listen. (4673)

Some staff even grabbed my breast and just pushed it inside my

babys mouth. This did not teach me how to feed my baby, it

was awful. (2228)

Relatively few women reported this type of intrusive

physical intervention, but those who did so were con-

fused and upset by it.

Communication with and between staff about care

was an issue at times, with overt antagonism between

midwives and doctors and a critical attitude toward the

women themselves:

Some doctors, midwives, and nurses made me feel stupid when

I asked a question or talked down to me, though it was my sec-

ond child. (5677)

Midwives talked loudly at night. They didnt explain the medi-

cation they gave me were always losing my notes. Theybitched about the night staff and vice-versa. They treated me

like I was stupid and didnt explain anything. Midwives didnt

hide their dislike for the doctors. (3407)

Feeling caught between groups of health professionals

worked against women feeling confident about their care

or their ability to cope and underlined the inconsistent

approach that women sometimes complained of more

directly. A single unpleasant incident sometimes marred

postnatal care:

One midwife was offhand and unpleasant one night because my

2-day-old baby cried persistently, as if both I and my baby were

to blame. (2536)

Womens Emotional Reactions

Womens diverse responses to infant feeding and sup-

port are shown in the language used. They described

their feelings and reactions to staff and the way in which

successful or unsuccessful breastfeeding affected their

perceptions of themselves as mothers. They could feel

isolated, neglected, ignored, and lonely,

and if breastfeeding had not gone well, like a bad per-

son or a failure who had let the baby down.

Some were anxious at being in an unfamiliar environ-

ment with strangers, felt stressed, and sometimes fearful

of their new responsibilities; others were confused or

angry about conflicting advice and the lack of support.

First-time mothers in particular lacked confidence:

I was unhappy as my baby didnt take to breastfeeding and I felt

humiliated Both me and the baby were distressed. (4103)

I suffered a few difficulties breastfeeding my baby the mid-wives made me feel so guilty , they left me very upset anddown about myself a midwifes job is to support a motherand make her feel positive about herself . they should sup-port you with what you feel is right for you. (2436)

However, other womens emotional and practical

needs were better addressed in terms of confidence and

trust:

The midwives were absolutely fantastic and helped me withany problems that I had, such as trying to breastfeed properly,

they helped me feel more positive if I couldnt do things ona one-to-one basis if it was needed. (3801)

Once I had had the baby I did get a tremendous amount of sup-

port from the midwives with breastfeeding I was lucky tohave a couple of great midwives whose advice I trusted. (2687)

Learning the Hard Way

Many women felt isolated, left alone, and unsup-

ported. The tiredness and distress associated with trying

to breastfeed and feeling they were not doing very well

at what was meant to be a natural behavior overwhelmed

some women:

I was totally exhausted, scared and felt quite isolated. My baby

cried constantly and would not be put down at all . I neededa lot of support with breastfeeding. (2156)

I was very upset that after the traumatic birth of my daugh-

ter I was just sent to a ward and my husband sent home .

26 BIRTH 39:1 March 2012

just left alone with this new baby and felt very lonely and

scared . I wanted to breastfeed but struggled. (3471)

Breastfeeding specialists, counselors, or clinics are

available in some hospitals, but women might only

become aware of them after developing problems:

I already had cracked, sore nipples after 3 days and only saw

the same midwife for 1 day, then another on the next shift etc.

The breastfeeding advisor was only down the corridor and I

never knew and would have liked to have gone there myself

whilst in hospital; instead saw her at home after agony. (6231)

I was told at antenatal classes . that the hospital had a spe-cialist breastfeeding person. However, when I asked to see her,

it fell on deaf ears. As this was my first baby, I had no experi-

ence and looked upon midwives and nurses to help me, how-

ever, I felt I had to learn the hard way (on my own). (5616)

Some groups of women needed additional help and

care, feeling that they managed to breastfeed despite

a lack of support or they could have managed had

help been available. For example, after an operative

delivery, significant blood loss, or a long labor, they

expected to receive help on the postnatal ward:

Once my baby was born I had no care or assistance with feed-

ing nursing. As I was on a catheter I was unable to move aftermy epidural and was made to feel in the way when I had to

repeatedly call for help. (2389)

I was told that because of me having pre-eclampsia and an epi-

dural, I would get help feeding . When I asked for this . Iwas spoken to rudely and left feeling very upset. (5189)

Organizational Factors

Staff shortages, particularly of midwives, were put for-

ward as an explanation for poor care and negative

attitudes:

Midwives were obviously overworked and under-

staffed often moody and short-tempered. (3075)

Women reported having to be persistent in asking for

help and waiting for long periods for help to come. Oth-

ers felt that they were a nuisance asking for help so

frequently when there was clearly a shortage of staff:

Each time I asked for help I was given it, but I would have felt

much more relaxed if there was more of a presence by mid-

wives. I realised that they were extremely busy so felt like I

didnt want to bother them. (4928)

Some women perceived staff shortages to be a partic-

ular problem at night, feeling more alone at that

time.

Length of postnatal stay was a concern for some:

those who would have preferred a longer stay felt they

were expected to leave as soon they were physically

well, before breastfeeding was established and, in

some cases, before they were psychologically ready to

take on the responsibility of caring for a newborn

independently:

Would have liked to stay longer to feel more confident butfelt as I was expected to go as soon as physically well enough.

It was slightly scary as first baby. (1894)

Others preferred to leave sooner, some because of

poor staffing, some because they could not get enough

sleep in hospital:

Very bad wardunderstaffed. Felt neglected. No help advicegiven about breastfeeding baby care. Decided to go home sameday because standard of care so low, but would have liked to

have stayed a night if more care had been available. (2052)

Despite staffing-related issues, some women did make

positive comments about their experience of postnatal

care in hospital, although this was framed by recognition

of staffing problems:

They were so busy you felt you were being too demanding, the

staff were lovely but so overstretched. (2207)

I had inadequate care postnatal due to the lack of midwives on

duty. The midwives were always polite and courteous but were

not available all the time to give me the support I needed with

my breastfeeding. (3770)

Discussion

The data presented reflect the issues as perceived by

new mothers, many of whom initiated and continued

breastfeeding and some who did not. All of those who

responded recognized the importance of the topic for

them and their babies. They emphasized the need for

early support, help, and information, and recognized the

negative consequences for maternal self-esteem and

well-being.

The women who responded about infant feeding were

self-selected and were more likely to be older, with more

education, and of white ethnicity than women who did

not respond. They often had strong opinions and proba-

bly experienced more feeding problems. The postnatal

question was framed and designed to elicit suggestions,

with a view to collecting data that could support

improvements in the quality of care. Although many

women were critical, they also expressed positive views,

particularly at the end of the survey.

BIRTH 39:1 March 2012 27

The responses and the analysis provide insights. The

poor treatment received by some women suggests that

there is room for change. The underlying root causes of

poor care deserve further research, but one may specu-

late that midwives acting in this manner are likely to be

stressed, have problems in other areas, and not likely to

be enjoying midwifery. Some responses suggested that

staff shortages may be an influential factor, others that

more effective support and advisory systems need to be

in place to help new mothers with infant feeding and

care.

This study was limited by being based on written

responses to questions in a survey. In an interview,

probes can be used to explore the issues raised. How-

ever, women may give more forthright and honest

answers to a survey without feeling the need to convey a

positive image to the interviewer. Moreover, it was pos-

sible to look at the views of a much greater number of

women than would have been possible using other meth-

ods. Peer examination, in which the research process

and outcomes are discussed in an iterative way with

another researcher, increased the validity of the coding

and themes identified. Transferability of the findings can

to some extent be assessed from the detailed description

of the sample given in Table 1.

A summary of the literature on feeding support noted

the importance of consistent advice and information,

practical support, and respect for body boundaries (7).

When breastfeeding is a technically managed activity

and a hands-on approach used to attach the baby to

the breast, they may undermine womens confidence in

their own ability. The problem of conflicting advice has

been emphasized in another qualitative study (16) and in

these analyses. Another study highlighted the impor-

tance of time constraints on staff trying to provide a high

standard of care (17). In postnatal care, midwives and

nurses often do not have time to form relationships with

women, leading to labeling and stereotyping of the kind

that some women felt was in operation here. Some

women thought that staff saw them as bad mothers,

and some took on this identity, echoing other observa-

tions of breastfeeding women and health professionals

showing that for women breastfeeding is generally equa-

ted with being a good mother (18). A qualitative

study examining the association between breastfeeding

and depression noted the devastating effect of unfulfilled

expectations when women had difficulties breastfeeding,

and described the unsupportive, bossy, and judgmental

attitudes of some staff (19).

These study findings are consistent with the literature

described and with that arising in different country con-

texts (20,21). Women reflected on their own expecta-

tions and needs and their emotional and physical

vulnerability, with accounts of inconsistent advice, a

lack of postnatal support, and judgmental attitudes that

could affect the way they saw themselves as a mother, at

least for a time. Responding to the open question about

postnatal care, one mother, herself a nurse reminds us of

the need for basic care and communication:

I would not leave a new mother with stitches, sitting behind

closed curtains for hours and hours without any kind of contact.

I would not assume that because the patient is a nurse that she

does not require support with breastfeeding. I would ask how

she was and if she needed any more pain relief. (4642)

Implications for Practice

The qualitative data and the constructs that women used

in describing their experience emphasize the importance

of treating them as individuals and being aware of what

they may take away from the postnatal experience of

infant feeding. Women would prefer information given

in antenatal classes to be honest and realistic. Without

putting them off, it should be made clear that breastfeed-

ing is a skill that needs to be learned by women and their

infants, which can take time. Postnatal wards are often

understaffed, and women need to be prepared to ask for

help if they need it. The reality of the situation in many

maternity units, the limited postnatal support once home,

and information about postnatal groups and peer support

should also be mentioned. Peer support, both formal and

informal, has the potential to make a difference in this

context, particularly when targeted (22).

All midwives and nurses working with postnatal

women need ongoing training in breastfeeding support

to facilitate consistent advice and practical help, and to

foster a positive can-do attitude more broadly. The

role of lactation consultants could be more fully imple-

mented, and a breastfeeding champion in each mater-

nity unit could work with staff and parents. Routine

audit of training would help ensure that training objec-

tives are met and that women get the support they need

at this crucial time.

Conclusions

Many of the women who succeeded felt that they had

learned the hard way, and some of those who did not,

felt they were perceived as bad mothers and women

who had in some way failed at one of the earliest

tasks of motherhood. What women perceived to be staff

perceptions affected how they saw themselves and what

they took away from their early experience of infant

feeding. Women would prefer information given in

pregnancy to be realistic rather than idealistic. Midwives

working with postnatal women need ongoing training in

breastfeeding to enable them to support women

effectively.

28 BIRTH 39:1 March 2012

Acknowledgments

The authors wish to give many thanks to the women

who participated in the survey.

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