EXAMENSARBETE - KANDIDATNIVÅ
VÅRDVETENSKAP MED INRIKTNING MOT OMVÅRDNAD VID AKADEMIN FÖR VÅRD, ARBETSLIV OCH VÄLFÄRD
K2020:14
Perceived Breastfeeding Support during Hospitalization
A qualitative analysis of mothers’ blogs.
Liona Samplonius
Janice Karen Velazco
Examensarbetets
titel: Perceived Breastfeeding Support during Hospitalization A qualitative analysis of mothers’ blogs.
Författare: Liona Samplonius & Janice Karen Velazco Huvudområde: Vårdvetenskap med inriktning mot omvårdnad Nivå och poäng: Kandidatnivå, 15 högskolepoäng
Utbildning: GSJUK17h Handledare: Ida Gustafsson Examinator: Lena Nordholm
Sammanfattning
Att amning ger den bästa typen av näring, stärker anknytning och har såväl fysiologiska som psykologiska fördelar för båda mamman och barnet är välkänt sedan tidigare. När amningen strular kan det dock vara en anledning till negativa känslor och risk för depression. När ett barn eller en mamma blir sjuk och inlagd på sjukhus, kan problem med amning uppstå. Det stöd och den hjälp mammor får under sjukhusvistelsen upplevs ofta som otillräcklig eller till och med felaktig. Detta kan orsaka rubbningar i amningen och tidig avvänjning, vilket i sin tur kan leda till en längre vistelse på sjukhus och upplevt vårdlidande. Därför är syftet med denna uppsats att beskriva hur mammorna upplever amningsstödet från sjuksköterskor under sin sjukhusvistelse. För denna kvalitativa empiriska studie har vi gjort en kvalitativ innehållsanalys av 15 bloggar hämtade från Internet. Bloggarna publicerades mellan 2009-2018 varav 11 bloggar var från England och fyra var från Sverige. Resultatet presenteras i tre olika teman: stärkande stöd, att känna sig förminskad och att vara beroende av vårdpersonalens kunskap och kompetens. Det framkommer att amningsstöd upplevs som stärkande och meningsfullt när det är anpassat till individens behov, men att kvinnor upplever ett lidande när de känner sig förvirrade, maktlösa, och osedda. I diskussionen visas hur vårdpersonalens information och stöd påverkar kvinnans amningsupplevelse.
Nyckelord: Amningsstöd, sjukhus, mammors upplevelse, blogg, kvalitativ innehållsanalys, sjuksköterska, amning
Abstract
It has been well established that breastfeeding provides the best type of nutrition, strengthens the bond between a baby and his mother, and has both physiological and psychological benefits. However, when breastfeeding is causing difficulties, it can negatively impact the mothers’ well-being and even result in depression. When a baby or its mother is hospitalized, breastfeeding issues can arise. The support and help mothers receive during hospitalization is often seen as insufficient or even incorrect. This can cause breastfeeding disruptions and discontinuation, which in turn can cause a
prolonged hospital stay and suffering of care. The goal of this thesis is therefore to describe mothers perceived breastfeeding support by the nurses that cared for them. We have made a qualitative content analysis of 15 blogs about breastfeeding for this empiric qualitative study. The blogs were published between 2009-2018, 11 blogs were from England and four were from Sweden. The results were presented in three different themes: strengthening support, feeling reduced, and being dependent on the health professionals’ knowledge and competence. The results show that breastfeeding support is perceived as strengthening and meaningful when adapted to the individual’s needs. However, mothers experience suffering related to care when they feel confused, powerless, and unseen. In the discussion we show how health care personals information and support influences the mothers breastfeeding experiences.
Key words: Breastfeeding support, mothers experiences, blogs, hospitalization, qualitative content analysis, nurse, nursing
TABLE OF CONTENTS
INTRODUCTION _____________________________________________________ 1 BACKGROUND ______________________________________________________ 1 Benefits of breastfeeding ____________________________________________________ 1 Breastfeeding when the mother or child is hospitalized ___________________________ 2 Perceived breastfeeding support _____________________________________________ 3 The role of nurses __________________________________________________________ 4 PROBLEM STATEMENT ______________________________________________ 5 AIM ________________________________________________________________ 6 METHOD ____________________________________________________________ 6 Samples __________________________________________________________________ 6 Data collection ____________________________________________________________ 6 Ethical considerations ______________________________________________________ 7 Data analysis ______________________________________________________________ 8 RESULTS ____________________________________________________________ 8 Strengthening support ______________________________________________________ 8 Opportunity for privacy ___________________________________________________________ 9 Encouraging support _____________________________________________________________ 9 Feeling reduced __________________________________________________________ 10 The desire to be heard ___________________________________________________________ 11 Feeling dismissed _______________________________________________________________ 11 Breastfeeding does not feel prioritized ______________________________________________ 13 Being dependent on the health professionals’ knowledge and competence __________ 13 The need for practical guidance ____________________________________________________ 14 Lack of continuity ______________________________________________________________ 15 DISCUSSION _______________________________________________________ 16 Method discussion ________________________________________________________ 16 Results discussion _________________________________________________________ 17 Breastfeeding support perceived as ‘hit or miss’ _______________________________________ 17 Global health and sustainability ____________________________________________________ 19 CONCLUSION ______________________________________________________ 20 REFERENCES ______________________________________________________ 21
INTRODUCTION
During an internship on the paediatric ward, one of us noticed a mother struggling to breastfeed her four-week-old infant that had contracted the RSV virus. Although it was an absolute priority to get the baby to eat, the mother did not get any help or support with regards to breastfeeding her baby, and when the baby eventually ended up receiving tube feeding, the mother was not offered a pump to express milk until the next day. This led us to the question how well breastfeeding support is organised for children or mothers that are hospitalized.
A working breastfeeding relationship is beneficial to both the physical and emotional well-being of mother and child. However, when the child or mother becomes sick and hospitalized, mothers can experience problems with breastfeeding. The support and help mothers may receive while they or their infants are hospitalized can be experienced as inadequate or even incorrect. This can cause a disruption in breastfeeding or can lead to early weaning, which in turn can lead to a prolonged stay in hospital and might cause the whole family suffering related to care.
We hope this study can give an insight in how mothers perceive the breastfeeding support which nurses offer in a hospital setting, to reduce suffering related to care, and to show how hospital routines around breastfeeding can be improved further.
BACKGROUND
Benefits of breastfeeding
Breastfeeding provides the best kind of nutrition, strengthens the relationship between mother and child, and has many physiological and psychological benefits for both. Exclusive breastfeeding for at least six months reduces the risks of obesity, diabetes, high blood pressure and helps reducing the risk for several types of cancer for the child. (WHO 2001). Other studies show that the mother is also positively affected by breastfeeding. Breastfeeding protects against breast and ovarian cancer, reduces the risk of major bleeding from the uterus postpartum and reduces the risk of osteoporosis. In addition, the close contact breastfeeding provides strengthens the emotional bond between mother and child (Britton, Britton & Gronwaldt 2006; Gartner et al. 2005). Breast milk has a unique composition of nutrients and antibodies, and studies show that breastfed children have lower infection rates and are less likely to develop allergies than children who are fed infant formula (Kramer & Kakuma 2012). There is even a study that shows breastfeeding has a positive effect on the child's intellectual and motor development (Gartner et al. 2005).
However, breastfeeding is more than just nutritional. Suckling the breast also has a positive impact on both the infant and the mother. It calms and reduces the ability to perceive pain. Furthermore, breastfeeding involves intimate social interaction between mother and child, which may result in the release of the anti-stress hormone oxytocin. It is also suggested that it enhances the mother – infant relationship, contributes to a secure attachment and facilitates the process in which mothers and infants learn to adjust and adapt to the behaviour of the other (Bigelow et al. 2014; Uvnas-Moberg
1997; Blass & Watt 1999; Schore 2001). Despite of all the physical and emotional benefits, breastfeeding is not always an easy ride and it can also be a cause for suffering. For new mothers that plan to breastfeed their new-born babies initially, breastfeeding can be more difficult than imagined. Mothers can feel alone and exposed, they can have feelings of pain and guilt and the mothers’ well-being can be affected negatively (Palmér, Carlsson, Mollberg, & Nyström 2010, 2012). Moreover, negative experiences associated with breastfeeding may contribute to a higher risk of post-partum depression (Watkins, Meltzer-Brody, Zolnoun & Stuebe 2011) and can even develop a fear of breastfeeding (Palmer, Carlsson, Brunt, & Nyström 2015).
Breastfeeding when the mother or child is hospitalized
When a child or a mother is admitted to the hospital, it effects the whole family. Handing over the care of the sick child may result in emotional strain. Feelings of despair, powerlessness, hopelessness and disappointment can be experienced, and the feeling of leaving the responsibility for the child in the hands of healthcare workers can make parents feel helpless and useless (Holditch‐Davis & M iles 2000) . Hospitalization due to a disease that requires hospital care can disrupt an already established breastfeeding relationship or worsen the already existing breastfeeding struggles the mother and child have. In addition, the need to express milk might not always be recognized during hospitalization (Heilbronner et al. 2017).
Several studies show the health benefits of breastfeeding a sick child. Breastfeeding is less work for the baby compared to bottle feeding, and infants are more likely to desaturate when they are bottle fed. The amount of oxygen available to the sick child is greater while breastfeeding than bottle feeding, and the skin to skin contact helps the baby maintaining the right body temperature and contributes to more stable breathing. Infants with a congenital heart defect even grow better when breastfeeding versus bottle feeding (Marino, O’Brien & Lore 1995; Chen, Wang, Chang & Chi 2000; Combs & Marino 1993). Moreover, breastfeeding also provides emotional benefits for both mothers and infants, particularly when breastfeeding their hospitalized child. It improves the physical connection as well as the emotional bond between mother and child. Breastfeeding is seen by mothers as an opportunity to hold and connect with their infants (Boucher, Brazal, Graham-Certosini, Carnaghan-Sherrard & Feeley 2011). There are also studies which demonstrate the relationship between breastfeeding problems in combination with hospitalization and breastfeeding discontinuation. A study in Sweden stated that breastfeeding problems result to early weaning (Gerd, Bergman, Dahlgren, Roswall & Alm 2012). However, a study performed by McNeil et al. (2013) show that hospital re-admission of an infant older than eight weeks does not necessarily cause a negative impact on the duration of breastfeeding. Contrariwise, it is the mother's perception of her experience in communicating with a healthcare provider that is associated with breastfeeding duration, not the hospitalization of either mother or child.
Perceived breastfeeding support
Previous studies about perceived breastfeeding support demonstrate that an effective and sufficient breastfeeding support by health professionals has been found to be very important in increasing the mothers’ perception of support. According to these studies, health care professionals play a significant role in providing the support the mothers need. Braimoh and Davies (2014) stated that the presence and intervention provided by healthcare professionals influences the women’s understanding of their ability to breastfeed their child. In addition, mothers perceive that instructions and advice from healthcare providers facilitate successful breastfeeding. Yang, Brandon, Lu, and Cong (2019) identified that the perception of support increases when the health care workers provide the mothers official information about breastfeeding via professional books, classes and even videos. Practical guidance from health professionals also has an impact on the perception of support. Demirtas (2015) explained that practical breastfeeding support is perceived as beneficial because it helps increase the mothers’ self-confidence and awareness of their breastfeeding mistakes. Mothers also perceive a support that is strengthening when they experience a breastfeeding environment that is comfortable, peaceful and trustworthy, with the opportunity for privacy for both the mother and the child (Ericson & Palmér 2018).
Several studies also show that attitudes and practices of the healthcare professionals, especially nurses, affect the mothers’ perceived support. Blixt, Johansson, Hildingsson, Papoutsi and Rubertsson (2019) suggested that mothers consider the breastfeeding support as strengthening when their unique needs are met by the health professionals with responsiveness and respect. Brewer (2013) noted that positive attitudes and knowledge are required in order to provide breastfeeding support to mothers. In addition, an encouraging and strengthening support provides hope and a sense of security (Ericsson & Palmér 2018). According to Demirtas (2015), understanding, compassionate and individual care, can increase the mothers’ confidence and enhance the mothers’ feelings of personal empowerment to breastfeed. This is true according to Erikson’s caritative caring theory in which she explains that the caregiver sees the patient as a human being and allows caritas, love and charity to be present in the caring relationship (Eriksson 1987, p. 8). Arman (2017a, p. 23) also explains that presence, listening and conversation are important elements of care. Furthermore, Fenwick, Barclay and Schmeid (2008) stated that the verbal exchanges between a mother and a nurse influence the mother’s confidence, her sense of control as well as the connection between her and her baby.
In some cases, caregivers might not always have the right knowledge or even tend to give contradictory advice. Ranch, Jämtén, Thorstensson and Ekström-Bergström (2019) concluded that mothers perceive breastfeeding support as insufficient when they are not being listened to. This conclusion is shared by Foligno et al. (2020) who in their study wrote that the level of information and education regarding the benefits of breastfeeding given at a paediatric care unit was insufficient. In line with this, parents getting mixed or contradictory advice or experiencing lack of support in breastfeeding their child is an
example of suffering related to care. Eriksson, who coined the concept, defines suffering related to care as a type of suffering caused by the care (or lack thereof) or treatment they are receiving (Eriksson 2015, p. 81). Arman (2017c, p. 44) explains that lack of correct information and poor communication can cause the individual to suffer related to care because it hinders him/her in communicating his/her needs properly. Arman further explains that a person feels powerless if his/her experiences are ignored and not taken seriously by the healthcare provider. This in turn leads to apprehensions and uncertainty. An individual who is uncertain feels powerless to participate actively and lacks the opportunity to influence the type of care he/she needs.
The role of nurses
It is part of the nurses’ role to provide a person-centred care wherein both the patient and the patient’s family are treated with respect, understanding and is seen as unique with unique needs (Swedish Society of Nursing 2017). In this thesis, the mother is either the patient or a parent of the sick child. During this very challenging time, the support the mothers receive from the health professionals is very important.
Several studies suggest that healthcare professionals who come into contact with breastfeeding women and their children must have both the practical and theoretical knowledge, as well as being responsive to the mother's wishes and needs to strengthen her in her role to succeed with breastfeeding (Blixt et al. 2019; Ward & Byrne 2011). Hellings and Howe's (2000) study shows that the most common source of knowledge about breastfeeding for nurses and midwives is the length of education and that the most common way to get information is through literature. Kronborg, Vaeth, Olsen and Harder (2007) described that healthcare workers who receive training increase their self-confidence in guiding and creating common guidelines on breastfeeding and breastfeeding problems. The mothers thus receive more information and better technical support from those who receive the training compared to those who did not take part in it. As described in the Swedish Society of Nursing (2017), nurses have the responsibility to update their knowledge using evidence-based methods with the best available information based on science and proven experience in which the patient's needs and preferences is the fundamental principle. This is important to be able to provide the right support the mothers need. McLaughlin, Fraser, Young and Keogh (2011) also stated that nurses have the responsibility to advocate for a conducive and supportive environment for breastfeeding mothers.
Ekström, Matthiesen, Widström and Nissen (2005) emphasized in their study that breastfeeding knowledge is not enough, a positive attitude towards breastfeeding is also important to provide good support. Nurses with positive attitudes are more successful in promoting breastfeeding. As stated by Swedish Society of Nursing (2017), it is also a part of the nurse’s role to perform his/her tasks in a way that the patient is treated positively where his/her values, preferences and expressed needs are respected. Conversely, negative attitude can result to mothers feeling unheard and unseen, which can result to suffering related to care. These negative feelings can be alleviated by allowing the parents to participate in the care of their child. Nyström and Axelsson (2002) explained that stress and anxiety is reduced through maintaining a dialogue and
motivating the mothers to develop a relationship with their child. Arman (2017c, p. 43) explains that in order to prevent unnecessary suffering, nurses have to involve the patient and his/her family in an active way and ensure that they are informed and involved in the decisions regarding their care. However, it is a role that nurses learn by experience and continuous education. It is consistent with the study of McNeil et al. (2013) who concluded that there should be resources available to help the healthcare providers acquire the necessary skills so that they will be both supportive and non-judgmental. Furthermore, Ward and Byrne (2011) suggested that continuous breastfeeding education can help improve the nurses’ attitude towards breastfeeding. The Swedish Society of Nursing (2017) defines that nurses, in partnership with the patient and the patient’s family, have the responsibility to provide care in a way that integrity and dignity are not compromised. Both the patient and the patient’s family have the right to be seen and understood as unique individuals with unique needs, resources, values and expectations. Mantha, Davies, Moyer and Crowe (2008) stated that nurses can influence how mothers view breastfeeding through providing an individualised caring support that is suitable for the unique needs of the mother. An individualised breastfeeding support, as defined by Blixt et al. (2019), is a sensitive, individually adapted support by healthcare professionals that helps promote a positive breastfeeding experience. An individually adapted support makes sure that both the mother and the child receive the care and support best adapted to them which allow them to be actively involved in their care. As explained by Ekebergh (2017, p. 75), to be able to provide a care with quality and consistency, nurses should take into account the person’s life-world, which means that the person’s individuality is prioritised. This is based on Dahlberg’s concept of lifeworld and patient perspective as the basis for caring, wherein the focus is in the person’s unique situation (Dahlberg & Segesten 2010, p. 126).
PROBLEM STATEMENT
Both the mother and the child are put in a vulnerable situation when either one of them is sick and hospitalized, which may affect the breastfeeding relationship and breastfeeding goals. Getting the right support and adequate information is an important factor in assisting the mother and the child during this crucial time. The amount of studies that are similar to the aim of this thesis are not that extensive. Previous studies on breastfeeding support show that hospitalization of either the child or mother could be associated with alterations of breastfeeding, and that severity of the illness and lack of support from the nurses could be associated with unwanted weaning. Breastfeeding support is not offered as a course during basic level nursing school, and there are few studies which show the importance of the nurses’ role in providing the right breastfeeding support the mothers need in the hospital setting. This leads us to further explore the mothers’ experiences and perception of breastfeeding support to be able to provide and help improve the nurses’ knowledge regarding this subject.
AIM
The aim of this thesis is to explore how mothers experience the breastfeeding support they receive from the nurses during hospitalization.
METHOD
A qualitative research design based on content analysis was chosen as analysing method to suit the aim of this thesis. A manifest content analysis describes the visible components of written content and is used for analysing documentation in a scientific way (Olsson & Sörensen, 2011, p. 210).
Samples
For the qualitative content analysis, the contents of 15 blogs written by mothers about their experience of breastfeeding support during hospitalization in both Sweden and England were used. Blogs were used because its contents tell the readers about the writers’ views, perceptions, feelings and experiences on a certain subject (Wilson, Kenny, Dickson-Swift 2015). Furthermore, it allows the writers a freedom of expression, thus, has been considered as a common source for gathering information for qualitative methodologies (Hookway 2008). Hence, blogs are a suitable source to collect data from for analysis.
Data collection
To get randomized results for our qualitative content analysis, we used Google to search for blogs. We searched blogs that were written in both Swedish and English. We used the following search criteria: ‘blogs’, ‘breastfeeding support’, ‘hospitalization of child’, ‘nurses support’. We started by searching google using the words ‘hospital’ + ‘breastfeeding’ + ‘support’. This gave us 82.600.000 results. We briefly scanned through the first 50 results, but they were irrelevant for our purpose. The main hits were about hospital policies, studies, and websites with information about breastfeeding a sick child. We added the term ‘blog’, which narrowed the results down to 18.100.000. We looked through the first 50 results, but they still did not provide the type of content we were looking for. Eventually, we used the terms: ‘Hospitalbreastfeeding’ + ‘blog’. This search query gave us 285 results. We looked at the titles of the first 50 hits, of these 50 we chose five blogs to read further and chose to use the ones that met our criteria. By clicking on the other related links provided in the blogs, we found even more useful material that met our criteria, from which we used six blogs. We continued our search in Swedish with the terms: ‘amningsstöd’ + ‘sjuk’ + ‘barn’ + ‘bloggar’. This has given us 7.800 results. We looked at the titles of the first 30 hits and chose to read the four blogs that on first sight seemed to meet our criteria. Of these four blogs, we could use two blogs. To collect more relevant Swedish data, we tried the following key words: ‘amningsberättelse’ + ‘sjuk’, which gave us 2500 hits. We looked at titles of the first 30 and opened 15 of them. We used two blogs that met our criteria, which gave us
enough material to analyse. See table 1 below for more information about the analysed blogs.
Our inclusion criteria include stories written by the mothers themselves, mothers who had been (at least partially) breastfeeding during hospital admission, and that they described the perceived support they received from the health care personal during hospitalization. Each blog contains stories of mothers during their short stay in a paediatric care unit or during hospitalization for their own illness.
When selecting the material, we excluded the blogs that did not meet the inclusion criteria. Only the blogs that were written to describe the mothers’ feelings about their breastfeeding experience in the hospital were selected. Mothers’ experiences of the support from midwives, breastfeeding support groups and doctors were also excluded since this thesis aims to describe only the support given by the nurses. Most of the blogs mentioned healthcare workers and nurses, we chose to use the terms healthcare workers, health professionals or healthcare providers to avoid confusion, since the mothers and children in this blog were hospitalized and stayed in different kinds of wards during their hospitalization. Because we did not include blogs about the care on postnatal care wards, the care of midwifes is not included in this term.
Table 1: Information about the analysed blogs. .
Total used blogs in content analysis: 15
Shortest blog: 547 words
Longest blog: 3328 words
Average blog length: 1320 words
Swedish blogs: 4
English blogs: 11
Hospitalized in Sweden: 2009 (1), 2016 (2), 2018 (1) Hospitalized in England: 2013 (1), 2014 (3), 2015 (2) Unknown date of hospitalization in
England: 5 (data collected on the same blogsite suggests hospitalization between 2010 - 2015, but this is not confirmed.)
Ethical considerations
The blogs used in this thesis are publicly available, therefore, there is no need for permission to use them. We have, however, chosen to keep the name of the authors anonymous when quoting them to protect their integrity. This is in accordance with the four important concepts for research ethics as explained by Swedish Research Council (2017), namely: secrecy, professional secrecy, anonymity and confidentiality. The basic principle, according to Swedish Research Council (2017), is that public documents shall be publicly accessible and that the Public Access to Information and Secrecy Act shall protect all information that is covered by secrecy. Information covered by secrecy entails professional secrecy, particularly for those who work in health care. Anonymity is defined by removing personal information of the participants so that a certain answer
would be not be linked to a certain individual. And confidentiality is used to protect the privacy and integrity of the participants.
Data analysis
The materials were reviewed based on Lundman and Hällgren-Graneheims (2017, p. 223) qualitative content analysis. Qualitative content analysis is used to analyse the communicative content. A blog falls into the category “written stories” and can be, in many ways, likened to an interview, which makes it a valid analysing method (Dahlborg-Lyckhage, 2017, p. 171).
All the blogs gathered are written in a narrative form. We numbered the blogs from 1 to 15 and distributed the stories where we would read seven to eight stories each. We read all the blogs assigned to each and took out the content considered useful for the aim of our thesis. We discussed the content each gathered and reviewed all the stories together to obtain a deeper understanding and analysis. A content analysis was used to systematically find a pattern and theme in the content. We collected all the quotes in a table and organised them in domains, subthemes and themes. Every blog was reviewed to catch as much relevant data as possible.
RESULTS
Three themes emerged from the mothers’ narratives: “strengthening support, feeling reduced, and being dependent on the health professionals’ knowledge and competence. The themes are organized into seven sub-themes (Table 2):
Table 2.
Strengthening support Feeling reduced Being dependent on the health professionals’ knowledge and competence 1. Opportunity for privacy 2. Encouraging support 1. Desire to be heard 2. Feeling dismissed 3. Breastfeeding
does not feel prioritised
1. The need for practical guidance 2. Lack of continuity
Strengthening support
Strengthening support includes the mothers’ positive experiences of breastfeeding support where mothers are provided with opportunity for privacy and encouragement, which in turn, empowers the mothers in breastfeeding despite them or their child being sick. Two sub-themes emerged under this theme: opportunity for privacy and encouraging support.
Opportunity for privacy
Mothers consider that they receive a support that is strengthening when they are provided with a comfortable place with the opportunity for privacy to facilitate breastfeeding. They express appreciation that they are able to get a private room in order to breastfeed during their hospital stay. A number of mothers appreciate that nurses make arrangements that enable them to breastfeed in private. This is expressed by one of the mothers in the following way:
"We were admitted to pre-op, but baby and Lee weren't allowed in. I explained I wanted to feed Clara up until my op so again a side room (an office actually) was found and cups of tea brought for Lee! None for me though as I was nil by mouth!"
(Blogger 07)
Mothers also describe a positive experience when the nurse shows sensitivity to her need for privacy. One mother that needs surgery expresses it is nice not to need to argue her case, the hospital staff has already thought about her need for privacy.
"Shortly after going back to the relatives’ room one of the senior nurses popped in and introduced herself. ‘I'm just trying to find you a bed...' she said. ...'and it may take a little bit of time as obviously I need to find you a private room for you and little one and I need to source a cot from maternity or the Kingfisher ward'. Oh, she'd already thought of it. There was no need for me to have to state my case...”
(Blogger 06)
The same mother expresses being glad she does not have to feed in front of drunk people when she has to wait for her turn at the emergency care. For this mother, it is strengthening support because the health care workers, through small gestures, has shown consideration and provides her the opportunity for privacy.
"Being allowed to use the relatives room was a welcome gesture. Not only did it prevent my daughter from being exposed to potential infection, it also allowed me to get some rest (sleep when the baby sleeps eh?) and also breastfeed in private. "
(Blogger 06)
Encouraging support
When health care professionals are able to provide a listening ear and encouraging words in order to support both the breastfeeding mother and her child, the support that mothers experience is strengthening. Mothers express their appreciation of being able to get this kind of support from healthcare professionals during their hospital stay. Mothers express that a simple act of kindness from health professionals gives them a peace of mind and makes their stay in the hospital a lot easier.
"I was visited by one of the medical team at about 4am to perform more tests Lucy was feeding. I was just about to unlatch her when the doctor (who I'm sure was not exactly flush for time) said 'oh no, don't take her off, I'll come back in half an hour'. In the morning the nurses were happy to 'bend the rules' on visitors and let my husband stay all day to help look after my daughter. Their only stipulation was that they got to have a cuddle with Lucy."
(Blogger 06)
Having your child hospitalized means you hand over a big part of your child’s care. Encouragement therefore is a big help to empower mothers get through this challenging time. Being able to breastfeed and being encouraged that the child would benefit of their milk make some of the mothers feel useful. Which one mother describes in the following way:
" An amazing nurse came and sat with me, she showed me how to use the hospital pump, she was so kind and was so encouraging that Percy would benefit from my milk."
(Blogger 01)
The presence of health care workers also gives encouragement. Although, a number of mothers admit that they are not expecting much from the healthcare workers, mothers still consider that their presence can help them get through this challenging time. Mothers express that having someone there to help with latching on correctly, getting advice about positions and expression, and just having someone who listens made a big difference. As one mother states:
“In the hospital there was a wonderful night nurse who was trained in breastfeeding support. I wish I could remember her name. She came and helped me to wake him every few hours through the night. She recommended that I pump the hard, sore breast to relieve the pressure. She also helped me with my latch, showed me different holds and let me just talk.”
(Blogger 06)
A strengthening support that provides hope and security to mothers is also encouraging. Some mothers express that this kind of support can last a lifetime. One mother describes that she will never forget the nurse who had encouraged and had supported her.
I will never forget that nurse. I am not sure I would have succeeded in continuing to breastfeed without her support. Thanks to her help in those crucial first few days, I was able to breastfeed my son for over 2 years.
(Blogger 08)
Feeling reduced
Mothers have the desire to be heard and to be included in the care of their child. When breastfeeding support fails to meet those needs, the mother feels reduced in her role as a parent. Feeling reduced includes situations where mothers feel unheard, dismissed and
unimportant by the health care workers. Three sub-themes emerged under this theme: the desire to be heard, feeling dismissed and breastfeeding does not feel prioritized.
The desire to be heard
It is expected that breastfeeding support makes sure the mothers feel secure and appreciated. The mothers expect being listened to and their difficulties being acknowledged. However, it is not always the case and the mothers feel reduced. Some of the mothers recall situations where instead of being listened to, they feel unheard and anxious. One of the mothers describes that she feels unheard when the health care workers do not even bother to check on her and her baby nor ask how they are doing. "Nobody asked us if we were okay. Nobody cared that my baby was screaming. We were just left in a room until eventually a nurse came in and said, 'she's hungry, isn't she?' "
(Blogger 10)
Another aspect of feeling reduced is when the mothers feel unseen and unheard by the healthcare workers. Mothers describe that they need to beg for help because they feel that their needs are not being listened to and taken seriously. When the nurse fails to acknowledge the mothers’ challenging situation, the mothers’ desire to be heard is not fulfilled.
"The nurse on the night shift saw my nipple shields and started gagging! And then refused to come near me! I had to beg again for pain relief for my child. "
(Blogger 10)
Although some of the mothers express that they are often visited by the nurses and checked upon, some mothers feel anxious and alone because during these visits, the nurses are more focused on the hospital routines rather than actually asking about what the mothers really need. This makes the mothers feel reduced.
"On days with an anxious nurse I'd be asked questions like "how empty do you feel" after feeding him, like they wanted it in ml’s for their chart, or "how much do you think he's had", it felt like I was the first mum to ever breast feed on the ward and made me feel really anxious and quite alone. "
(Blogger 01)
Feeling dismissed
Breastfeeding mothers often feel reduced because they feel excluded and dismissed by health professionals as if their choices and decisions are not important. A number of mothers feel that some nurses openly show negative attitudes towards them for opting to breastfeed their sick child. This makes them feel that their decision is dismissed and
disrespected by the health professionals. One mother expresses that the nurse’s lack of empathy makes her feel awful.
"The nurses sat at the nurses' station and glared at me. One even told me that if I had formula fed then Beth would be settled by now and someone less sleep deprived could have stayed with Beth and given her a bottle.... I cannot tell you how awful this made me feel. "
(Blogger 10)
This includes the feeling of frustration when the nurse fails to empathize with the difficulties of the mother breastfeeding a sick child. The mothers’ need for understanding are easily dismissed, thus, making them feel reduced. Mothers express that breastfeeding a sick child is not the same as breastfeeding in normal circumstances. "One nurse said, “well you need to be able to feed anywhere so you better get used to it”! The point was I was living in that cubicle! Feeding every 4 hours for 2 weeks! It's not like I'd been caught on the hop and had to have a one-off awkward feed. Gosh, I can feel the frustration building in me again! "
(Blogger 03)
It is also an aspect of feeling reduced when the mothers feel dismissed because the healthcare workers do not care for their need for privacy. A number of mothers express that when curtains are asked to be drawn all the time so that the nurse can see the mother and the child, they feel that their need for privacy is dismissed by the health care workers. Although many realize it was not intentional, one mother feels vulnerable when her privacy is not taken into consideration.
"...the curtains were pulled back and ward round had arrived! A consultant, about 4 junior doctors and a couple of nurses; and me with my boobs out! I thought they'd excuse themselves while I covered up, but they didn't; nudity doesn't bother me that much, but it made me feel really vulnerable, I tried to pull my hoodie around me but that did very little; and once I'd put Percy on the bed I was pretty much half naked! "
(Blogger 01)
Some of the mothers also feel dismissed by the health professionals when they fail to encourage and support mothers in their decision to breastfeed. This make the mothers feel reduced. Mothers express that the lack of support not only affects the mothers but also the children.
“Of course, not every mother will want to breastfeed. Of course, the hospital should support individual’s feeding choices, especially when parents are already under pressure due to a child’s illness. But at the moment it is the mothers who desperately want to breastfeed who are being let down. And by extension their children are being let down.”
Breastfeeding does not feel prioritized
Some mothers feel breastfeeding is not really seen as an important part of the paediatric care they receive. Other mothers feel like breastfeeding is reduced to food only for the infant, and the focus is only on milk production and the technical aspects involving feeding the infant. When breastfeeding is not prioritised in the hospital, mothers feel that their decision to breastfeed is unimportant, thus making them feel unimportant too. “The overall impression I got was that breastfeeding was seen as a lifestyle choice, which some nurses supported, and others did not, but it was certainly not seen as an important part of paediatric care.”
(Blogger 13)
Mothers believe that the structured feeding routine implemented in the hospital is not conducive to their breastfeeding attempts. Mothers express they feel the emotional and even physical benefits of having the baby on their breast are forgotten by many health care providers which make the mothers feel unimportant to their child's wellbeing. One mother describes how the hospital did not even make any attempts to help her have her baby on her breast.
“Once David was cleared to feed orally the hospital started him on bottles of my expressed milk. They never suggested latching him on and I couldn’t be bothered to get into it with them”
(Blogger 14)
It is also described by the mothers that health care workers are too quick to suggest formula feeding rather than encourage breastfeeding. This in turn make them feel like the healthcare workers do not care about the importance of establishing a breastfeeding relationship between mother and baby. Thus, making the mother feel that her role as a mother is reduced.
“I was offered no help or advice at all with my breastfeeding whilst I was in hospital. Looking back, I can't believe they didn't offer any help at all to keep me breastfeeding.”
(Blogger 04)
Being dependent on the health professionals’ knowledge and
competence
Mothers often rely on the knowledge and competence of the health professionals about breastfeeding. How much information and practical guidance the mothers receive affects the perception of the support they get. Lack of knowledge and inconsistency in the advice and information provided has a negative impact on the continuity of support the mothers receive. This theme is organized by two sub-themes: the need for practical guidance and lack of continuity.
The need for practical guidance
Practical guidance is described as an important aspect of breastfeeding support. Mothers wish that they are provided with concrete information and practical tips about everything breastfeeding involves. The practical guidance that mothers prefer includes how to express milk, correct latching, proper positioning of the infant as well as interpreting the babies’ signals. However, this practical kind of support is not always experienced as sufficient by the mothers. Several mothers report there are times when they receive an explanation about the mechanics but are not offered help with the actual expressing of milk. The mothers wish that they are guided accordingly rather than just being informed.
"I was given a pump to express to feed her but I wasn't really shown how to use it apart from the mechanical side of things (here's the on and off switch and this make its suck harder) so it didn't really work! "
(Blogger 04)
This also includes situations where mothers receive information, but it is not the kind of information they expect to receive. One mother explains she appreciates the nurses’ support in helping her to express milk, but she expects more support with breastfeeding instead.
“The nurses gave support to express, taught how to use a pump and offered water, privacy and vouchers for free meals, but no help to breastfeed.”
(Blogger 02)
There are also circumstances where mothers do not receive any desired information at all. Some mothers write about not receiving guidance on correct latching, for example. One mother writes about a nurse insisting the latch looks fine, despite the mother feeling it is not right. More information and guidance are expected from the nurse, but not obtained.
“And I suspect none of them we met really knew how to help a parent and a baby how to latch on correctly on their own…If they knew they didn’t succeed in helping us anyway. Or we were just unlucky and didn’t meet the individuals among the personnel that did have the right knowledge”
(Blogger 15)
Practical guidance is also considered insufficient when the mothers are not given information on possible and better alternatives. One mother expresses that the nurses never suggested latching on. If this guidance had been given before, it could have made her situation easier. Some mothers even complain they are not given information on where to throw away or store their expressed milk. These are concerns that the mothers wish to obtain information about. One mother writes that a nurse did not make an effort to provide her with an alternative solution to her query to express milk.
"I asked if there was a breast pump I could use to express as Beth wasn't really feeding, she just wanted the comfort and I was so full. The nurses said, "we don't have one". "
(Blogger 10)
Lack of continuity
Inadequate support is characterized by a lack of reciprocity and inconsistency. The continuity of support depends on the consistency of the information provided and the interplay of reciprocity between the mother and the health care workers. Healthcare workers have the responsibility to provide correct advice and information to the mothers. In return, the mothers trust that the information they receive from healthcare providers is reliable. Some mothers express that they do not really trust the advice they get from the healthcare workers they meet in the hospital setting when the advice is inconsistent. One mother explains that she does not really know how strict the feeding routines in the hospital are.
Each nurse was different around his feeding as well, he was "prescribed" x amount of milk per hour, which some stuck to the ml and others where more relaxed about.
(Blogger 01)
Lack of communication between different healthcare workers and receiving conflicting information is also experienced as a cause for unnecessary suffering. Mothers feel that healthcare professionals are unreliable, and they do not know what to trust anymore. The gap in knowledge among healthcare professionals leads to confusion and feelings of insecurity. One mother was informed by the nurse that she could not breastfeed her sick son, but the opposite turned out to be true. She suspects the nurse told her this for her own convenience.
"The nurse hadn't communicated this with me, I felt like she'd done this because it made her life easier, so there was no ambiguity about how much he was having. I was furious. The nurse was sheepish for the rest of her shift and later told Andy that she felt she had "let us down".
(Blogger 01)
Honest information is also expected from the healthcare workers. The mothers wish that the healthcare workers are honest in telling them that they lack the right knowledge, instead of pretending, which one mother describes like this:
“It would have actually benefited me if the breastfeeding nurse and midwives at the
ward had said: “Honestly, we can't do this as well as we would like. It may be better if you contact the breastfeeding clinic here at the hospital or contact the Breastfeeding consultant. "
In the hospital setting, there is often confusion about medication and breastfeeding. Some mothers feel that the health professionals are not updated about which medication is safe or not while breastfeeding, which can result in receiving conflicting information. One mother writes she has to throw away her milk after expressing, due to the pain medication she receives. At the same time the nurses do not allow her more pain medication because she is breastfeeding. She feels like a failure and wonders why she is not offered any alternative.
“Why was it allowed to come to the point where a nurse was encouraging me to give up breastfeeding? Why was it presented to me as a choice between breastfeeding and pain relief?”
(Blogger 05)
DISCUSSION
Method discussion
For this thesis, we have used an empirical qualitative method and the material has been reviewed using a qualitative content analysis based on domains, categories and themes. (Lundman & Hällgren-Graneheim 2017, p. 223). The empirical qualitative method was chosen because it is the experience of how the mothers perceived breastfeeding support in the hospital setting that was desired to be investigated. Our initial plan was to conduct 4-6 semi guided qualitative interviews. However, this did not prove feasible both for ethical reasons and due to the time window available for this assignment. For this reason, we chose to analyse already published blogs instead. The quotes we used are the parts of the blogs that are relevant to the aim of the study, and these quotes form the basis for our analysis.
We, as the authors of this thesis, are also mothers with our own experiences with breastfeeding support. There is, therefore, a risk that we might base our interpretation of the blogs on our own experiences and preconceived opinions. In order to produce a possible credible result, only the information that the blog authors wrote about is used. Our own interpretations were set aside. There was a lot to consider once the blogs had been reviewed and analysed. As readers of the blogs, we had to keep in mind to stay objective and not to project our own preunderstanding to the content of the blog. Nyström (2017, p. 182) explains that preunderstanding is defined as the image the researcher has of the subject to be studied. Nyström notes that while some scientists believe the author should put their understanding within parentheses, others believe that in doing so could mean that the message is at risk of being lost. It is further explained that interpretation is often unconscious and cannot, therefore, be put in parentheses. Moreover, Lundman and Hällgren-Graneheim (2017, pp. 224-227) explain that the text itself does not always have a given meaning but can be interpreted in several ways. In line with the explanation above, careful considerations were taken into account to be able to stay critical and conscious of our own preunderstanding during the analysis of our material. It helped us avoid the risk that the results we see are too general, and not enough in depth. Furthermore, to be sure the written word was not taken out of context, we also consider what has been written in the sentences before and after the taken quote.
The emotional message of the written word in the blogs used was sometimes difficult to perceive, which can mean the written message can be taken out of context. We tried, therefore, to conserve the message of the quotes we analysed in the way the authors meant them.
As opposed to writing a literature review, the credibility of scientific articles is often high because they are peer-reviewed and must meet certain criteria to be eligible for publication. The credibility of blogs, however, can be questioned because a blog does not need to be reviewed critically before publication. It is difficult to compare the credibility between a blog and a scientific article. We chose to analyse blogs because a blog can be more like an interview, where the writer can freely choose what to write down. By using the blogs, we get the uncensored experience of how mothers perceived the breastfeeding support they received in the hospital. At the same time, no one questions or double-checks whether the content of the blog is actually true. This too can be likened to an interview as you can never be sure whether what the interviewee says is the truth.
We chose our inclusion criteria because we wanted first-hand stories of breastfeeding mothers’ personal experiences and perceptions of breastfeeding support in the hospital setting. To make sure our results are about the support mothers received from nurses, we excluded stories that mainly described situations involving midwifes or doctors. The results of this study are women's real experiences and we aim to contribute to an increased understanding and continued discussions about the subject.
Results discussion
This thesis aims to describe how mothers of sick infants or mothers that were hospitalized themselves perceived breastfeeding support during hospitalization. The results show that the mothers perceive the support as strengthening, but a support that is inadequate can also make them feel reduced. The results also show that mothers are dependent on the quality of health professionals’ knowledge and competence.
Breastfeeding support perceived as ‘hit or miss’
With ‘hit or miss’ we mean ‘hit’ as sufficient and ‘miss’ as insufficient support. It is what the mothers describe in their blogs in terms of breastfeeding support. The described support depends highly on the healthcare provider they meet in the hospital setting. Our results show that some mothers perceived they received sincere support and were met in their needs, while others felt diminished in their breastfeeding experience depending on the knowledge, approach and support style provided by the healthcare professionals. This is supported by several studies. When the mothers received a support that is individually adapted to their needs which empowers them in their role as mothers, it is perceived as sufficient support (Blixt et al. 2019; Ericson & Palmér 2018; Holditch‐Davis & M iles 2000; Mantha et al. 2008).
As shown in our results, inconsistency of advice and information provided by healthcare workers affects the mothers’ perception of breastfeeding support. A previous study stated that mothers experience a lack of cooperation among the health professionals
and being torn between differing information and advice based on the professionals’ personal beliefs and opinions about breastfeeding (Ericson & Palmér 2018). In this context, inconsistency occurs because what the health care workers think is suitable for one mother can be different for the other. The support given is based on what the caregiver thinks is right and not on what the patient really needs. To avoid this, the patient’s lifeworld should be the central point of caring (Dahlberg & Ekebergh 2017, pp. 95-96). They further explain that lifeworld perspective is essential because it allows the caregiver to understand how it is for the patient to be sick and how it is for the patient’s family to see that their loved one is sick. They also state that lifeworld perspective gives opportunity for the patient to participate in his/her care, giving importance to the idea that the patient is the expert on what he/she really needs. Our results also show that the mothers’ trust and confidence towards the health care workers is affected by inconsistency. Despite Yang, Brandon, Lu and Cong (2019) stating that mothers trust the advice they get from healthcare professionals, we find that the opposite is true when the advice they get from healthcare workers they meet in the hospital setting is inconsistent. This leads to confusion and feelings of insecurity among the mothers. Ekebergh and Dahlberg (2017, pp. 129-131) say that the caring relationship is affected when the patient lacks confidence and trust towards the health care workers.
Inconsistency, as shown in our results, can also be caused by knowledge deficit about breastfeeding among healthcare workers, which can result in a low perception of support. Our results identify that health professionals lack sufficient knowledge regarding the benefits of breastfeeding. When the important benefits of breastfeeding are dismissed, the mother feels dismissed and unimportant in her role as a mother. This is consistent with the study of Hong, Callister and Schwartz (2003) who found that women feel in control when they were provided with sufficient information regarding breastfeeding. Blixt et al. (2019) also described that women wanted additional knowledge about breastfeeding. Nurses are therefore required to regularly improve the quality and efficiency of patient education (Buchko, Gutshall & Jordan 2012).
Moreover, it is also presented in our findings that mothers wish they received practical support which allows them to learn proper breastfeeding techniques. This agrees with Boucher et al. (2011) who explained that mothers need to be reassured about their ability to breastfeed effectively. Our thesis shows that nurses play a pivotal role in providing mothers with positive reinforcement surrounding their attempts to breastfeed. This is in line with the core competence of nurses which states that nurses have the responsibility to involve the patient as well as her family in her care, and to provide and share the necessary information needed to promote self-care (Swedish Society of Nursing 2017). Weiss and Lokken (2009) identified in their study that mothers’ ability to care for themselves and their new-born increase when they are provided with more information.
Our results also show that health care workers tend to focus on routines and guidelines, which makes the mothers feel excluded, causing them to suffer related to care. This is consistent with the study made by Demirtas (2015) who stated that breastfeeding problems are associated with mothers who felt misunderstood and unseen because there was a lack of interaction with the nurses. Ekebergh and Dahlberg (2017,
pp. 129-131) explain that it is through communication where the nurse relieves the person’s suffering and promotes well-being. Without this kind of interaction and communication between the nurse and the mother, it is perceived as a support which is inadequate. Ericson and Palmer (2018) described that inadequate support results to mothers feeling insecure and abandoned. Arman (2017c, p. 41) explains that the feeling of being abandoned and alone is the most common cause of suffering. Arman further writes that it is fundamental for nurses to continuously deepen and increase their knowledge and understanding of the human suffering because suffering is the basis and motive of caring.
Erikson (1987, p. 7) says that caring is a basic human nature. However, according to Arman and Rehnsfeldt (2006), people also have a tendency to hold back and alienate themselves from their caring nature. Arman (2017b, p. 192-194) explains that caring culture and traditions hinder the caritas-based caring. This creates an invisible barrier between the caregiver and the patient, which can cause the caregiver to be too nonchalant and affects the quality of care that is being provided. Erikson (1987, p. 26) explains that caring is a form of nurturing, playing and learning. Nurturing, according to her, is to show that you really care for the other person even through small actions. Playing is the caring relationship and the connection that is formed between the caregiver and the patient. Learning is the part of caring where the health provider learns about the patient, and vice versa. Erikson says learning is a continuous process. As shown in our results, when the nurses put an effort in learning about the expressed needs and preferences of the mother, the mothers also learn that the nurses bring about dignity, thoughtfulness and joy in their caring. In return, it empowers the women in their role as mothers and at the same time increases the mothers’ confidence in the nurse’s ability to provide an adequate and individually adapted care and support. The support that is given is consistent and reciprocated, thus, alleviating the suffering the mothers experience. As Hong, Callister and Schwartz (2003) explained in their study, caring and supportive behaviours from nurses make the mothers feel understood, validated and believed in.
Global health and sustainability
Recent studies have highlighted the harmful effects of infant formula to the planet. Not only does it produce greenhouse gas, but it also depletes other resources such as water and electricity. Cow milk production also depletes paper, produces plastic waste and even incurs transportation costs during the multiple stages of milk production and advertisements. Moreover, powdered cow milk uses additives such as palm, coconut, vegetable oils, and fish oil because it is nutritionally inadequate (Joffe, Webster & Shenker 2019).
Globally, out of the 141 million babies born annually, there is only 41 percent who are exclusively breastfed until six months (Unicef 2019). Aside from the health benefits of breastfeeding to infants and to mothers, breastfeeding uses fewer resources and produces minimal or zero waste. It is therefore very important that mothers are well informed on the importance of breastfeeding their newly born. An adequate and effective breastfeeding support for mothers is therefore highly encouraged, particularly during hospitalization of either the infant or the mother.
As health care providers, nurses have an important role in supporting the mothers to achieve their breastfeeding goals. It is part of the nurses’ role to provide adequate and correct information regarding the health benefits of breastfeeding, which in turn not only helps save lives, but also saves the healthcare system’s resources and billions globally (Bartick & Reinhold 2010). A study made by Ward and Byrne (2011) suggests that a breastfeeding support by knowledgeable, well-trained, healthcare workers especially nurses and midwives, is effective in increasing the amount of time the mother breastfeeds. Whereas, lack of knowledge, inconsistency in advice given, as well as perceived lack of support from health professionals can cause the mothers to wean their child early or even affect the mother’s initiative to breastfeed.
Effective and continuous breastfeeding education for nurses can, thereby, help improve the nurses’ knowledge, skills, and attitudes towards breastfeeding, which in turn contributes to an increased perception of support. In line with global health and sustainability, breastfeeding education helps improve breastfeeding outcomes, which in turn can help reduce the costs of formula feeding concerning health, environment and economy.
CONCLUSION
This thesis shows that there is inconsistency in the type of breastfeeding support mothers receive when their child is hospitalized. When being put in a vulnerable situation like hospitalization, it is easy for the mothers to be affected both positively and negatively by the health professionals. It is, therefore, very important that mothers receive breastfeeding support that is individually adapted to their needs. Mothers feel confident in their ability to breastfeed when they receive individually adapted breastfeeding support and are provided with correct and sufficient information as well as empowerment from health care professionals. This in turn allows them to be actively involved in their care and in the care of their child, thus, increasing the perception of support, which in turn, can contribute to global health and sustainability. However, factors such as the healthcare providers’ knowledge, skills and attitudes towards breastfeeding can influence the perception of breastfeeding support. While it is understandable that not all healthcare providers have the right kind of knowledge to support a breastfeeding mother during hospitalization, a situation where lactation support is needed should be recognized, and the right professional should be called in to aid the mother and baby. This thesis suggests that breastfeeding protocols and continuous education for hospital staff about breastfeeding are really needed.
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