1. Kathryn Hinsliff-Smith Rachel Spencer Denis Walsh
How breastfeeding can be an emotional rollercoaster: A qualitative study of primigravid women in Lincolnshire
Kathryn Hinsliff-Smith
Rachel Spencer
Denis Walsh
School of Nursing, Midwifery and Physiotherapy
Academic Division of Midwifery

2. Background Breastfeeding is a key public health priority
WHO optimal way to feed infants up to 6 months
Improving health outcomes, via improved breastfeeding rates, has the potential to save NHS funds (Renfrew et al. 2012)

3. Local context Breastfeeding initiation per PCT 2009/2010
England 72.7%, East Midlands 72%, Lincolnshire 71.8%
Breastfeeding rates at 6 – 8 weeks
England 49%, East Midlands 45%, Lincolnshire 40%
Lincolnshire Hospital Trust BFI level 2 accredited
Lincolnshire PCT commission 2012, 12 month project
9/2/2019
Event Name and Venue

4. Research aim
To develop an understanding of primiparous women’s experiences and challenges of breastfeeding in the early postpartum period (6-8 weeks) “

5. Methods Primigravid women over 34 weeks Recruitment (May until August)
Information letter and consent form
Planned birth at Boston, Grantham, Lincoln
Antenatal and postnatal care in Lincolnshire
Data collection
Written diaries returned from 22 women for the first 6 weeks after birth
A sub-sample of 13 women agreed to an in-depth face to face interview conducted in their home at 6/8 weeks
Overall 26 women shared their infant feeding experience
Aim to recruit 40 actually achieved 48
22 of 48 women 46% return rate for diary –no difference in the demographics between those that completed and those that didn't return
1 withdrawl, 3 excluded due to maternal or newborn complications, one pre-term at 34 weeks
Interviews 10 planned ( 5 breastfeeding, 5 stopped) actually 13 conducted ( 4 still breastfeeding and 9 who had ceased)
Rationale diary and interview: triangulate data, interview to explore in detail their experiences and to identify the contextual factors, that affected their decision to continue or discontinue b/f
Diaries provide a means to capture relevant events and emotions which each participant could record at that moment, not retrospectively. Disadvantages include failure of participants to use their diaries, forget or feel uncomfortable (shown before, discussed and provided prompt cards)
Indeed the Zimmerman and Wieder 1977 discuss the appropriateness of utilising diary and follow up interview

6. Findings
Three conceptual themes identified

7. Emotional rollercoaster of infant feeding
maternal guilt
unpreparedness for breastfeeding
unrealistic expectations
Professionals: notions of expertise, communication and impact
perceived power of ‘experts’
breastfeeding communication and support
Dimensions of public feeding
feeding in front of family and friends
using private facilities in public spaces
feeding ‘where ever and when ever’

8. Feeding at hospital discharge Feeding pattern at 6 weeks
Table 1 – Infant feeding outcome of 26 participants
Feeding at hospital discharge
Feeding pattern at 6 weeks
Breastfeeding including EBM 18 10
Formula
Mixed 7 1 16
Total 26
100% (26) mothers confirmed that they initiated breastfeeding and experienced skin to skin contact (as per BFI good practice)
EBM expressed breast milk (2 of the 18)
at hospital discharge 18 (68%) of sample b/f
By 6 – 8 weeks 18 to 10 a drop to 38% of sample

9. Emotional rollercoaster of infant feeding
maternal guilt
unpreparedness for breastfeeding
unrealistic expectations
Researchers metaphor
Breastfeeding most of today, he has barely left my chest (p19 diary)
He feeds every two hours and I find this difficult (p42 diary)
I was not expecting it to be like this (constant feeding) (p32 diary)
He never went more than an hour between feeds at night (p25 diary)
Researchers metaphor on the paradox between healthcare professionals providing adequate advice/support enabling them to make informed decisions and the realities for them once they give birth
Mothers experienced a transient emotional position because of their decision to stop b/f of their lack of knowledge about newborn behaviour. They were unprepared for the realities of looking after a newborn and saw their b/f as the problem compared to those that were formula feeding.
Messages around breast is best were well understood by the mothers and indeed were recited verbatim however this presents a picture of it being “unproblematic and natural” (Andrews and Knaak 2013) study in Canada and Norway

10. Professionals: notions of expertise, communication and impact
perceived power of ‘experts’
breastfeeding communication and support
She (midwife) came in and said you are doing it wrong, you do not look like you are sat right, and you don’t look comfortable (p10 diary)
She (midwife) was not helpful at all. When I was hand expressing she said, that is not worth giving it to him, and she put it in the sharps bin. I was so mad (p30 interview)
Day 11 My health visitor told me off. She said I was confusing him [baby]. I don’t know what to do, either try him on my boob again and see how it goes or keep him on a bottle now. I feel so bad (p36 diary).
This relates to the perceived ‘experts’ the healthcare professionals to whom the participants sought advice and guidance (includes community midwives, hospital midwives and health visitors).
Mothers were very complementary about labour ward staff
And on the wards mothers described wanted solutions to the b/f difficulties – they judged success as weight gains, filling nappies and babies not crying
The nature and type of communication with mothers was paramount to how they (mothers) viewed their breastfeeding abilities – in particular (unsurprisingly negative comments affected the mothers QUOTES ABOVE new mothers appear particularly vulnerable to negative comments
Of the 26 mothers who shared their experience only 3 made an active effort to access and form of b/f support group

11. Dimensions of public feeding
feeding in front of family and friends
using private facilities in public spaces
feeding ‘where ever and when ever’
Important to emphasise that all the mothers (48) intended to breastfeed and for those we interviewed (13) we captured why they made this choice but we did not capture antenatally how long they intended to breastfeed as we were only interested in the first 6 weeks and now whether they would be continuing to the 6 month milestone.
We did not interview them about any societal barriers or who they might overcome b/f in ‘public’ but they discussed described this in the diaries and in our interviews (4 b/f) about ‘normal everyday tasks and trying to b/f
Mothers talked about performing in front of family and friends whilst in hospital and for some using the curtains to create ‘private’ space.
Mothers who’s immediate family breastfeed appeared to have less difficulty but not with the inlaws

12. - Final Report with findings, conclusions and recommendations submitted to NHS Lincolnshire December Report reviewed and approval gained for dissemination - Lincolnshire Infant Feeding Strategy 2013 – 2016 currently under review
To date 21 women who took part in the study have requested a full copy of the report with all 48 receiving a letter providing the findings and recommendations

13. Key Messages
In preparing women for the realities of breastfeeding their newborn there is a need to include the difficulties that mothers may experience and should be explicitly included in antenatal preparation
Predictable, scheduled, ongoing support, both on the postnatal ward and throughout the early postnatal period when discharged home is recommended. Breastfeeding support should be proactive rather than reactive.
Approaches need to be taken that promote breastfeeding as the ‘norm’ and that continue to provide supportive environments for breastfeeding mothers.

14. Key Message – data collection
Diaries provide a useful means of collecting data that enables mothers to describe and reflect upon their infant feeding journey, providing researchers with useful contemporaneous data of mothers lived experiences.

15. Thank you Please feel free to take a copy of the report or request an electronic copy