Prenatal and postpartum focus groups with primiparas: breastfeeding attitudes, support, barriers, self-efficacy, and intention

The effects of video-assisted breastfeeding education given to primiparous pregnant women on breastfeeding self-efficacy: randomized control study

BACKGROUND

Breastfeeding is vitally important for the health of the mother, baby, family and society. Especially the perception of breastfeeding self-efficacy of primiparous pregnant women is an important factor in breastfeeding. This study was conducted to determine the effects of online video-supported breastfeeding education on breastfeeding self-efficacy in primiparous pregnant women.

METHODS

This randomized controlled study was conducted with primiparous pregnant women admitted to a university hospital in northern Turkey. The study involved 80 pregnant women, with 40 assigned to the experimental group and 40 to the control group. Participants in the intervention group received online video-assisted education, which covered the first meeting of the mother and baby as well as the initial breastfeeding session. The data for the breastfeeding self-efficacy scale were gathered at the onset of the study and three weeks later. In data analysis, categorical variables were assessed using the chi-square test, continuous variables and intergroup comparisons were conducted through the independent sample t-test, and intragroup comparisons were performed using the paired sample t-test.

RESULTS

While the baseline breastfeeding self-efficacy levels of the primiparous pregnant women were similar between the groups, statistically significant differences were observed both within (p = 0.000) and between (p = 0.000) groups in the breastfeeding self-efficacy scores of pregnant women in the intervention group after the education intervention.

CONCLUSION

Breastfeeding self-efficacy levels in the education group showed a statistically significant increase compared to both the pre-education and control groups. This highlights the importance of nurses providing support to primiparous pregnant women through video-assisted education during pregnancy to enhance breastfeeding self-efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06121973 date of first registration (27/10/2023), retrospectively registered (08/11/2023).

Spicing up food interactions: Development of a healthy food education activity targeting fathers and their young children

BACKGROUND

Childhood obesity rates have been rapidly increasing worldwide. Several actions to reduce this trend have addressed maternal feeding practices. However, research reports an unwillingness to taste healthful foods expressed by children and fathers, which represents a major obstacle to a healthy diet in the family household. The present study aims to propose and qualitatively evaluate an intervention to increase fathers' involvement with their families' healthy eating through exposure to new/disliked healthy foods.

METHODS

Fifteen Danish families took part in a 4-week online intervention involving picture book reading, a sensory experience session and the cooking of four recipes with four targeted vegetables (celeriac, Brussels sprouts, spinach and kale) and two spices (turmeric and ginger). Interviews were conducted with the families and the content was analysed through a blended or abductive approach.

RESULTS

Participating in the activities motivated children and fathers to try new vegetables and spices, and increased fathers' sense of self-efficacy toward cooking, tasting new foods and healthy feeding. For the family, the intervention acted as a trigger to consume a higher variety of vegetables and spices and prompted feelings of "food joy". The outcomes observed are of importance considering the relatively low cost and the remote approach of the intervention.

CONCLUSIONS

The results highlight the fact that fathers play an important role in the home food environment. We conclude that fathers should be included to a higher extent in food and nutrition strategies aimed at promoting healthy weight development in their children.

Forming the Perception of WIC Infant Feeding Recommendations: A Qualitative Study

Nearly half of newborns in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Promoting breastfeeding is a programmatic priority, although formula vouchers are provided for those who do not exclusively breastfeed. Previous literature suggests that participant perception of WIC's breastfeeding recommendations is a significant factor predicting breastfeeding initiation, duration, and exclusivity outcomes. However, little is known about how participants' perceptions of WIC's breastfeeding recommendations are formed. To address this knowledge gap, we conducted a qualitative pilot study in Nevada, interviewing 10 postpartum WIC mothers and 12 WIC staff who had interacted with participants regarding infant feeding. Results showed participants and staff reported various perceptions of what WIC recommends, the factors that contribute to these perceptions, and how these perceptions affect breastfeeding practices. Respondents also described that WIC has a negative legacy as the "free formula program," and that environmental factors, such as the recent formula recall, have had an impact on participants' infant feeding practices. More effective public campaigns and programmatic strategies are needed to target participants' prenatal self-efficacy and to communicate the availability of skilled lactation support in the early postpartum period to improve participants' perceptions of WIC's position on breastfeeding.

Welcoming, supportive care in US birthing facilities and realization of breastfeeding goals

BACKGROUND

Emotional and physical support for birthing parents is positively associated with realization of their breastfeeding goals. However, few studies have investigated maternal descriptions of their postnatal unit experience of these domains.

RESEARCH AIM

The objective was to investigate maternal report of their birthing facility experiences and quantify the extent to which accounts of postpartum support were associated with meeting their breastfeeding goals.

METHODS

After IRB review, data were obtained through an online survey distributed from November 2016-May 2017. This analysis utilizes data from 2,771 birthing parents who were at least 18 years of age, experienced maternity care in the United States within five years, and reported that they had intended to breastfeed. Bivariate analysis was followed by logistic regression controlling for significant covariates.

RESULTS

In this sample of primarily non-Hispanic white birthing parents with intent to exclusively breastfeed, the following postnatal unit variables were associated with higher odds of meeting their breastfeeding goals, birthing parents feeling: welcomed (adjusted OR=1.36), that health care promoted their physical health (adjusted OR=1.41), that care promoted their emotional health (adjusted OR=1.38), that they were supported (adjusted OR=1.56), and that they were recognized by their health care team (adjusted OR=1.30). All the measured postnatal unit support variables were significantly correlated with each other, with correlation coefficients ranging from 0.15 to 0.81.

CONCLUSIONS

Before the COVID-19 pandemic, birthing parents' experiences on the postnatal unit were interrelated and associated with meeting their breastfeeding goals. As health care services are reviewed and prioritized during the COVID-19 pandemic and as part of ongoing strengthening of systems, qualitative and observational research can address the mechanisms underlying breastfeeding outcomes to inform the provision of more holistic and effective support.

Estimating the Impact of In-Hospital Infant Formula Supplementation on Breastfeeding Success

Objective: To assess whether in-hospital infant formula supplementation impacts later successful breastfeeding among healthy mother-infant dyads in the United States who are not intending to exclusively use infant formula. Study Design: Using secondary analysis of a national longitudinal survey (Infant Feeding Practices Study II, n = 2,399), we estimated effects of in-hospital infant formula supplementation on later breastfeeding success by matching mothers whose infants received in-hospital formula supplementation with mothers whose infants did not. Estimates were compared across four matching methods. Outcomes of breastfeeding success included likelihood of following a sustained breastfeeding trajectory for the first year postpartum; feelings of favorability and breastfeeding as long as desired postweaning; and breastfeeding intention, initiation, and duration for subsequent children. Results: In-hospital formula supplementation halved the likelihood of following a breastfeeding trajectory characterized by sustained exclusive breastfeeding. Supplementation decreased feelings of favorability toward breastfeeding postweaning but did not impact the likelihood of feeling that one breastfed as long as desired. Supplementation did not impact intention to breastfeed a future child; it did, however, decrease the likelihood of breastfeeding initiation with a subsequent child by >66% and reduced average duration of breastfeeding any subsequent children by >6 weeks. Conclusion: A lack of experimental methodologies in previous studies makes it difficult to determine a causal link between infant formula in the hospital and less breastfeeding success. Assuming we have accounted for all appropriate confounders, this study provides evidence for such a causal link. Birth hospital policies and practices should speak of this risk of harm.

Compliance of mothers' breastfeeding and complementary feeding practices with WHO recommendations in Turkey

BACKGROUND/OBJECTIVES

This study aimed to evaluate how breastfeeding and complementary nutrition practices of mothers of 0-24-month-old children comply with the World Health Organization (WHO) recommendations for infant and young child feeding and to compare the results with selected demographic parameters related to the mother and child.

SUBJECTS/METHODS

The research sample comprised mothers (n = 250) with children less than 2 years old. Data were obtained via questionnaire and were analyzed using SPSS 20.0 package program. The Pearson χ2 or Fisher's exact tests were used for assessing relationships between categorical variables. The one-sample t-test was used for comparisons with reference values.

RESULTS

Most mothers (97.2%) breastfed their babies immediately after birth. The mean time to breastfeeding after delivery was 47.8 ± 14.8 minutes, and 40.8% of the mothers complied with the WHO recommendation. Furthermore, 59.8% of the mothers exclusively breastfed their children for 6 months (mean 5.2 ± 1.5 months). The mean duration to the start of providing complementary food was 5.8 ± 0.6 months, and 76.1% of mothers who complied with the WHO recommendation. Only 12.3% of mothers breastfed their children for at least 12 months (mean 7.7 ± 3.3 months). On average, mothers gave cow milk to their children for the first time at 10.1 ± 1.7 months and honey at 11.8 ± 2.3 months. The mothers' rates of compliance with the WHO recommendations on cow milk and honey feeding were 32.0% and 71.6%, respectively. The rate of mothers who complied with the WHO minimum meal frequency recommendation was 88.3%.

CONCLUSIONS

We suggest that the WHO recommendations on this subject will be realized more fully by emphasizing the importance of the positive effects of breastfeeding until the age of 2 years and of a timely start of complementary food provision. Such changes will affect child health over the long term.

The individual focus of nursing research in breastfeeding: Perpetuating a neoliberal perspective

In this paper, I argue for the need to shift the focus of nursing research regarding breastfeeding from that of individual responsibility to include a more system-focused, population health approach. In the 2011, "Call to Action to Support Breastfeeding," the U.S. Surgeon General called attention to the pervasive disparities in breastfeeding outcomes in the United States. A plethora of nursing research exists aimed at addressing these disparities; however, this research leans toward a neoliberal perspective, mainly focusing on individual factors and failing to address the systemic inequities contributing to these disparities. A shift in nursing science that focuses research at a population level would more effectively support addressing disparities in breastfeeding outcomes and embrace a commitment to social justice. In focusing at a population level, specific inequities that must be addressed include the negative history of breastfeeding in the Black population, systemic racism, and gender inequality. Critical research methodologies are proposed as useful approaches to address these inequities. By engaging in this level of research and using a critical lens, nurse scientists broaden their scope of care to include the entire population, motivate needed social and policy change, facilitate the choice to breastfeed, and ultimately eliminate breastfeeding disparities.

Validation of the Infant Feeding Beliefs Questionnaire (IFBQ) among pregnant African- American women and their study partners

Maternal feeding beliefs and practices have been associated with weight gain in infants and young children. Less work examines feeding beliefs prenatally or the feeding beliefs of other non-maternal caregivers (NMCs) who play important roles in infant feeding. This study validates a scale, the Infant Feeding Beliefs Questionnaire (IFBQ), to assess feeding beliefs during pregnancy among African-American women and other caregivers and tests whether the resulting belief constructs (laissez-faire, restrictive, responsive, pressuring and indulgent) are associated with maternal and NMC characteristics. Data come from 429 pregnant women and 374 NMCs including fathers, grandmothers and other family and friends enrolled in the baseline 28-week gestation visit of the Mothers and Others Study, a family-based, randomized control trial to support healthy infant feeding and prevent obesity. Confirmatory factor analysis (CFA) was used to test the fit of four a priori feeding constructs. Models were modified iteratively in mothers and then separately tested in the NMCs sample. Construct scores were created by averaging the remaining items and scale reliability was assessed. External validity was tested using bivariate and multivariable regression models. We validated five feeding belief constructs, measured through 8 sub-constructs. Reliability coefficients ranged from 0.58 for laissez faire to 0.76 for pressuring. Goodness of fit indices for CFA models indicated good fit with CFIs from 0.97 to 0.99 and RMSEA from 0.00 to 0.06. Construct scores differed significantly by depressive symptoms, obesity, education, income, and previous children in mothers and NMCs. The IFBQ may be used among mothers and NMCs to assess feeding beliefs beginning in the prenatal period, providing a tool to assess the longitudinal development of feeding beliefs and to highlight avenues for intervention on feeding practices during a critical period for behavior change.

A systematic review and meta-analysis of interventions incorporating behaviour change techniques to promote breastfeeding among postpartum women

The benefits of exclusive breastfeeding are well documented, yet few women adhere to recommendations. We report the Behaviour Change Techniques (BCTs) within interventions trialled internationally after pregnancy to promote exclusive and mixed breastfeeding as well as evidence of effectiveness. PsycINFO, EMBASE and MEDLINE databases were screened. Twenty-three (n = 23) studies met inclusion criteria. Three authors independently extracted data, coded interventions using the BCT v.1 taxonomy, and assessed study quality. There was a moderate significant effect of the interventions promoting exclusive breastfeeding up to four weeks postpartum (OR 1.77, [95% CI: 1.47-2.13]) but this effect slightly declined beyond thirteen weeks (OR 1.63, [95% CI: 1.07-2.47]). Twenty-nine BCTs were identified within interventions. 'Credible source' and 'instruction on how to perform the behaviour' were the most prevalent and 'social support (unspecified)' contributed to the effectiveness of exclusive breastfeeding interventions five to eight weeks postpartum. Using BCTs with cognitive and behavioural aspects may help women develop coping mechanisms promoting exclusive breastfeeding. Further trials are needed in countries with low breastfeeding rates such as the UK. The use of programme theory during intervention development and clear description of intervention components is recommended. This meta-analysis provides guidance for trials evaluating postpartum breastfeeding interventions.

The perceptions and experiences of women with a body mass index ≥ 30 kg m2 who breastfeed: A meta-synthesis

Breastfeeding has copious health benefits for both mother and child, but rates of initiation and maintenance among women with a body mass index (BMI) ≥ 30 kg m² are low. Few interventions aiming to increase these rates have been successful, suggesting that breastfeeding behaviour in this group is not fully understood. Therefore, this review aimed to systematically identify and synthesise the qualitative literature that explored the perceptions and experiences of women with a BMI ≥ 30 kg m² who breastfed. The search identified five eligible papers, and a meta‐ethnographic approach was taken to synthesise the findings. One theme was identified: “weight amplifies breastfeeding difficulties,” revealing that women with a BMI ≥ 30 kg m² experience common breastfeeding difficulties to a greater degree. In particular, women with a BMI ≥ 30 kg m² struggle with the impact of medical intervention, doubt their ability to breastfeed, and need additional support. These findings can inform understanding of breastfeeding models, future research directions, intervention development, and antenatal and post‐natal care for women with a BMI ≥ 30 kg m².

Postpartum Pain in the Community Among Migrant and Non-migrant Women in Canada

International migrant women of childbearing age represent a large proportion of immigrants to high-income countries, yet research focusing on their postpartum health is limited. We investigated predictive factors for breast and non-breast pain 1 week post-birth in migrant and non-migrant women in Canada. Among migrant women, difficulty accessing health services; being from a middle-or high-income country; poor functionality in English and French; living with the father of their infant; and having no regular care provider were predictive of breast pain. Among non-migrant women, difficulties accessing health services, multiparity and prenatal education were predictive of breast pain, while receiving an epidural and having no regular care provider were predictive of non-breast pain. Among both groups, difficulties accessing health services and having no regular care provider were predictive of breast pain, while second degree or higher perineal tearing was predictive of non-breast pain. Migration-specific indicators should be considered in postpartum care planning.

Timing of return to work and women's breastfeeding practices in urban Malaysia: A qualitative study

Nearly half of the working population in Malaysia are women, and with only a short period of maternity leave, they may struggle to achieve the recommended 6 months of exclusive breastfeeding. The aim of this paper was to explore the relationship between the timing of return to work and beliefs and breastfeeding practices among women in urban Malaysia. A qualitative inquiry based on a phenomenological framework and multiple methods was used: face-to-face interview, participant diary and researcher field notes. Data collection took place in Penang and the Klang Valley, Malaysia, from March to September 2011. Eligible participants were purposely identified at randomly selected recruitment sites. A thematic analysis method was used to develop the typologies and categories of the findings. A total of 40 working women with a mean age of 32 years (SD 3.4) were interviewed and 15 participated in the diary writing. Most women (75%) returned to work between 2 and 3 months. Only 10% returned to work 4 months or later postpartum, and 15% had an early return to work (defined here as less than 2 months). The women fell into three groups: Passionate women with a strong determination to breastfeed, who exclusively breastfed for 6 months; Ambivalent women, who commenced breastfeeding but were unable to sustain this after returning to work; and Equivalent women, who perceived formula feeding as equally nutritious as breast milk. Although longer maternity leave was very important for Ambivalent women to maintain breastfeeding, it was not as important for the Equivalent or Passionate women. In conclusion, returning earlier was not an absolute barrier to continuing breastfeeding. Instead, a woman's beliefs and perceptions of breastfeeding were more important than the timing of her return to work in determining her ability to maintain breastfeeding or breast milk feeding.

Tecnologias educativas para promoção do (auto) cuidado de mulheres no pós-parto

RESUMO Objetivo: avaliar a literatura nacional e internacional sobre o uso de tecnologias educativas para promoção do autocuidado de mulheres no pós-parto. Método: trata-se de uma revisão integrativa da literatura. As produções foram coletadas nas bases CINAHL, SCOPUS, PubMed, SciELO, LILACS e Cochrane, utilizando como recorte temporal o período de janeiro/2004 a julho/2014, nos idiomas português, inglês, espanhol e francês, selecionadas a partir dos descritores: postpartum period, educational technology, nursing e self care. Ao final, procedeu-se à análise de 27 artigos. Resultados: dentre as informações, observou-se que as escalas, o aconselhamento e a visita domiciliar foram as tecnologias educativas mais recomendadas. Conclusão: as tecnologias favorecem a comunicação, mas por vezes são dependentes de computador e internet, dificultando o acesso para mulheres de baixa renda.

Expectant parents' views of factors influencing infant feeding decisions in the antenatal period: A systematic review

OBJECTIVE

To explore the factors that influence expectant parents' infant feeding decisions in the antenatal period.

DESIGN

Mixed method systematic review focussing on participant views data.

DATA SOURCES

CINAHL, Medline, Embase and PsychInfo databases were interrogated using initial keywords and then refined terms to elicit relevant studies. Reference lists were checked and hand-searching was undertaken for 2 journals ('Midwifery' and 'Social Science and Medicine') covering a 3 year time period (January 2011-March 2014). Key inclusion criteria: studies reflecting expectant parents' views of the factors influencing their infant feeding decisions in the antenatal period; Studies in the English language published after 1990, from developed countries and of qualitative, quantitative or mixed method design.

REVIEW METHODS

A narrative interpretive synthesis of the views data from studies of qualitative, quantitative and mixed method design. Data were extracted on study characteristics and parents' views, using the Social Ecological Model to support data extraction and thematic synthesis. Synthesis was influenced by the Evidence for Policy and Practice Information and Co-Ordinating Centre approach to mixed method reviews.

RESULTS

Of the 409 studies identified through search methods, 17 studies met the inclusion criteria for the review. Thematic synthesis identified 9 themes: Bonding/Attachment; Body Image; Self Esteem/Confidence; Female Role Models; Family and Support Network; Lifestyle; Formal Information Sources; Knowledge; and Feeding in front of others/Public. The review identified a significant bias in the data towards negative factors relating to the breastfeeding decision, suggesting that infant feeding was not a choice between two feeding options, but rather a process of weighing reasons for and against breastfeeding. Findings reflected the perception of the maternal role as intrinsic to the expectant mothers' infant feeding decisions. Cultural perceptions permeated personal, familial and social influences on the decision-making process. Expectant mothers were sensitive to the way professionals attempted to support and inform them about infant feeding choices.

CONCLUSIONS

By taking a Social Ecological perspective, we were able to explore and demonstrate the multiple influences impacting on expectant parents in the decision-making process. A better understanding of expectant parents' views and experiences in making infant feeding decisions in the prenatal and antenatal periods will inform public health policy and the coordination of service provision to support infant feeding activities.

Breastfeeding: What are the Barriers? Why Women Struggle to Achieve Their Goals

Despite recognized health benefits for both mothers and infants, significant disparities still exist in the rates of breastfeeding in the United States. Major organizations representing the health of women and children (including the Centers for Disease Control and Prevention [CDC], American Academy of Pediatrics [AAP], American Congress of Obstetrics and Gynecology [ACOG], American Academy of Family Physicians [AAFP], United Nations International Children's Emergency Fund (UNICEF), the World Health Organization [WHO], and the United States Public Health Service [PHS]) recommend exclusive breastfeeding, but statistics show that although many women initiate breastfeeding, few meet the recommended goals for duration and exclusivity. This article reviews the evidence related to barriers (prenatal, medical, societal, hospital, and sociocultural) that many mothers face, and explore the known barriers and the impact they have on a woman's ability to breastfeed her infant. Strategies will be discussed to address (and potentially overcome) some of the most common barriers women face along with a list of resources that can be useful in this effort. Gaps in care and areas that need further research will be noted. This article is targeted toward physicians and other healthcare providers who work with women and who can assist with and advocate for the removal of barriers and thereby improve the health of women and children by increasing the rates of breastfeeding initiation, duration, and exclusivity in the United States.

Cyprus mothers׳ breast feeding self-efficacy and their perceptions about the implementation of the '10 steps' in the first 48hours after birth

BACKGROUND

more than two decades after the launch of the '10 steps' for successful breast feeding, there is still concern that implementation is suboptimal. Commonly, studies assess the level of implementation based on self-assessments from maternity staff and more rarely based on the mothers' own experience. To date, there has been only anecdotal evidence with regards to the implementation of the '10 steps' in Cyprus while there is general lack of research data on breast feeding in this country.

AIM

this study assessed breast feeding self-efficacy among mothers during the first 48hours after birth and explored their views with regards to the implementation of the '10 steps' across public and private maternity units in Nicosia, Cyprus.

METHOD

this is a descriptive study with a consecutive sample of 216 mothers, aged at least 18, who gave birth to a full-term healthy infant between January and April 2014. Two data collection tools were used: Section 4 of the BFHI (Baby Friendly Hospital Initiative) questionnaire referring to mothers' self-assessment of maternity unit practices and the BSES-SF (Breast feeding Self-Efficacy Scale - Short Form) which measures perceived self-efficacy in bryeast feeding.

RESULTS

midwifery assistance for breast feeding skills development along with encouragement of breast feeding on demand (steps 5 and 8) were identified by mothers as the steps they were more likely to have experienced. In addition, there appeared to be relatively good adherence to the International Code of Marketing of Breast-milk Substitutes. In contrast, it seems that step 7(rooming-in), step 9 (no pacifiers) and step 10 (breast feeding support after discharge) were not systematically practiced. While a higher percentage of mothers in public maternity units reported being informed about the importance of skin-to-skin contact compared to the private sector (51.5% versus 25.7%), there does not appear to be much difference in terms of its actual practice which is generally low (29.0% versus 25.4%). Exclusive breast feeding (step 6) was low (21.7%) while the mean score of breast feeding self-efficacy at 48hours was 3.33 (0.87SD) on a 5-point Likert scale.

CONCLUSIONS

it appears that mothers in Cyprus had limited experience of the '10 steps' during their stay Nicosia maternity units. This, along with the fact that exclusive breast feeding and breast feeding self-efficacy were rather low, suggests the need for interventions that will enhance breastfeeding self-efficacy and empower mothers to initiate breast feeding while at the maternity unit. In particular, the limited information to mothers upon leaving the maternity unit highlights the lack of maternal support services in the community.

The enablers and barriers to continue breast milk feeding in women returning to work

AIM

To describe the enablers and barriers working women experience in continuing breast milk feeding after they return to work postpartum in urban Malaysia.

BACKGROUND

In Malaysia, urban working women have low rates of breastfeeding and struggle to achieve the recommended 6 months exclusive breastfeeding.

DESIGN

A qualitative enquiry based on a phenomenological framework and multiple methods were used to explore women's experiences in depth.

METHODS

Multiple qualitative methods using face-to-face interview and participant diary were used. Data collection took place in urban suburbs around Penang and Klang Valley, Malaysia from March-September 2011. Participants were 40 employed women with infants less than 24 months.

FINDINGS

Only 11 of the participants worked from home. Based on the women's experiences, we categorized them into three groups: 'Passionate' women with a strong determination and exclusively breastfed for 6 months, 'Ambivalent' women who initiated breastfeeding, but were unable to sustain exclusive breastfeeding after returning to work and 'Equivalent' women who introduced infant formula prior to returning to work.

CONCLUSION

Passion and to a lesser extent intention, influenced women's choice. Women's characteristics played a greater role in their infant feeding outcomes than their work environment.

Nurses and midwives professional support increases with improved attitudes - design and effects of a longitudinal randomized controlled process-oriented intervention

Background

Becoming parents for the first time is challenging. Mothers need both social and professional support to handle these challenges. Professionals’ attitudes affect quality of care and support. So to improve professional support, an intervention consisting of a process-oriented training was performed. Due to the positive results of the intervention there is a need to illuminate the methodological approach further. The overall aim was therefore to describe a methodological approach to improve and evaluate health care professionals’ attitudes toward breastfeeding and parental support in order to improve quality of care in childbearing.

Methods

This study was a longitudinal randomized control intervention study, in which groups of mothers received care in childbearing from midwives and child health nurses. These health professionals had gone through a process-oriented training, or not. In order to improve attitudes of health professionals the training was based on evidence, practical skills and reflective processes (both private and professional experiences) in relation to breastfeeding and parental support. Included in the longitudinal study were health professionals from five intervention municipalities n = 36 and health professionals from five control municipalities n = 45. All mothers who fulfilled the inclusion criteria were consecutively identified from the hospital register and asked to participate in the study. Mothers who accepted to participate were included in the interventions group (n = 206) or control groups (n = 162, n = 172 respectively) based on which municipality they belonged to.

Results

The results of the process-oriented training improved the professionals’ attitudes toward breastfeeding and parental support. These improved attitudes in health professionals increased intervention-group mother’s satisfaction with professional and social support. Intervention-group mother’s relation to and feelings for their baby as well as breastfeeding was also improved.

Conclusion

These results stress the importance of professionals’ attitude in quality of care during childbearing, as well as pointing to the possibility to improve professionals’ attitudes with a process-oriented training.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR), trial registration: ACTRN12611000354987.

Attention placebo control in randomized controlled trials of psychosocial interventions: theory and practice

Attention placebo control (APC) is considered a highly valid control condition when conducting trials of social interventions. Unfortunately, an appropriate APC condition is rarely used. This letter discusses the tension between methodological and ethical requirements of an APC group in psychosocial interventions based on our experiences with a randomized controlled efficacy study of a parent training program. To prevent negative side effects and high drop-out rates, feasible and accepted attention control conditions are discussed. The paradigms of placebo research must be adapted to the special challenges of psychosocial intervention research.

Trial registration: Clinicaltrials.gov NCT02313493: registered 10 December 2014

Breast-feeding support in Ireland: a qualitative study of health-care professionals' and women's views

OBJECTIVE

To examine women's experience of professional support for breast-feeding and health-care professionals' experience of providing support.

DESIGN

We conducted semi-structured qualitative interviews among women with experience of breast-feeding and health-care professionals with infant feeding roles. Interviews with women were designed to explore their experience of support for breast-feeding antenatally, in hospital and postnatally. Interviews with health-care professionals were designed to explore their views on their role and experience in providing breast-feeding support. Interview transcripts were analysed using content analysis and aspects of Grounded Theory. Overarching themes and categories within the two sets were identified.

SETTING

Urban and suburban areas of North Dublin, Ireland.

SUBJECTS

Twenty-two women all of whom had experience of breast-feeding and fifty-eight health-care professionals.

RESULTS

Two overarching themes emerged and in each of these a number of categories were developed: theme 1, facilitators to breast-feeding support, within which being facilitated to breast-feed, having the right person at the right time, being discerning and breast-feeding support groups were discussed; and theme 2, barriers to breast-feeding support, within which time, conflicting information, medicalisation of breast-feeding and the role of health-care professionals in providing support for breast-feeding were discussed.

CONCLUSIONS

Breast-feeding is being placed within a medical model of care in Ireland which is dependent on health-care professionals. There is a need for training around breast-feeding for all health-care professionals; however, they are limited in their support due to external barriers such as lack of time. Alternative support such as peer support workers should be provided.

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

BACKGROUND

The World Health Organization recommends promoting exclusive breastfeeding for six months. Women often end breastfeeding earlier than planned, however women who continue to breastfeed despite problems often experience good support and counselling from health professionals. The aim of this study was to evaluate the effects of a process-oriented training in breastfeeding support counselling for midwives and child health nurses, on women's satisfaction with breastfeeding counselling, problems with insufficient breast milk and nipple pain in relation to exclusive breastfeeding shorter or longer than 3 months.

METHODS

An intervention through process-oriented training for health professionals regarding support in childbearing and breastfeeding took part in the south west of Sweden. This study was conducted in Sweden, in 2000 - 2003. Ten municipalities were paired, and within each pair, one was randomly assigned to the group of five intervention (IG) municipalities and one to the group of five control municipalities. Primiparas (n = 540) were invited to participate in a longitudinal study to evaluate the care they received. A survey was distributed at 3 days, 3 months and 9 months postpartum. Data collection for control group A (n = 162) started before the intervention was initiated. Data for control group B (n = 172) were collected simultaneously with the intervention group (IG) (n = 206). Women were also divided into two groups depending on whether they exclusive breastfed < 3 months or ≥ 3 months.

RESULTS

Women in IG were more satisfied with the breastfeeding counselling (p = 0.008) and felt the breastfeeding counselling was more coherent (p = 0.002) compared to control groups, when exclusive breastfeeding was < 3 months. In addition fewer women in the IG, among the group exclusively breastfeeding < 3 months, had problems with insufficient breast milk compared to the control groups (p = 0.01).

CONCLUSION

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

TRIAL REGISTRATION

ACTRN12611000354987.

A qualitative study to understand cultural factors affecting a mother's decision to breast or formula feed

BACKGROUND

The presence of barriers is not sufficient to explain breastfeeding rate disparities. A relatively unexplored area in coping with breastfeeding barriers is culture.

OBJECTIVE

This research aims to better understand the role of culture in a woman's infant feeding decision by using race and socioeconomic status as indicators of culture.

METHODS

Focus groups and individual interviews were conducted with 42 pregnant women or mothers of infants younger than 12 months. Focus group composition was determined by self-identified African American or white race and self-reported eligibility for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or ineligibility (non-WIC).

RESULTS

Most participants acknowledged that breastfeeding was best, yet differences arose between groups in the perception of, and reaction to, breastfeeding barriers. WIC and non-WIC participants of both races indicated that some circumstances necessitated formula use. WIC participants felt that this was personally and socially acceptable due to need, whereas non-WIC participants felt that this was personally and socially unacceptable. When a barrier arose, WIC participants of both races felt that the infant feeding choice was not theirs and formula use might be inevitable. In contrast, non-WIC participants of both races expressed that they persevered to continue breastfeeding and did so by establishing small, achievable goals and seeking mentors.

CONCLUSION

Educational and public health efforts to reduce breastfeeding disparities may be enhanced if support is tailored to acknowledge cultural differences among women and address factors that make either breastfeeding or formula feeding acceptable, or even preferable, within their communities.

Women's perceptions of breastfeeding barriers in early postpartum period: a qualitative analysis nested in two randomized controlled trials

OBJECTIVES

This study examined women's perceptions of early infant feeding experiences and identified early postpartum barriers to successful breastfeeding.

SUBJECTS AND METHODS

We conducted semistructured exit interviews at 6 months postpartum with a subsample of participants (n=67) enrolled in two randomized controlled trials of breastfeeding promotion. Study arms included (1) routine pre- and postnatal visits with an International Board Certified Lactation Consultant (IBCLC) (LC group), (2) electronically prompted guidance from prenatal care providers (EP group), (3) EP+LC combined, and (4) standard of care (control group). Interview transcripts were coded using grounded theory and analyzed in MAXqda. Code matrices were used to identify early postpartum breastfeeding barriers and were further examined in relation to treatment group using a mixed methods analysis.

RESULTS

The majority of the participants reported experiencing at least one barrier to breastfeeding. Barriers to breastfeeding were more commonly reported in the early postpartum than late postpartum period. The most common barrier during the early postpartum period was the perception of inadequate milk supply ("lactational") (n=18), followed by problems with latch, medical problems that were perceived as precluding breastfeeding, and medical staff and hospital practices. Participants frequently reported that the IBCLCs assisted them in anticipating, managing, and overcoming these barriers.

CONCLUSIONS

Our findings underscore the importance of integrating IBCLCs into routine pre- and postpartum care because they provide critical support that effectively addresses early postpartum barriers to breastfeeding.

A descriptive qualitative review of the barriers relating to breast-feeding counselling

The purpose of this review was to describe barriers in breast-feeding counselling considering it from the viewpoint of health professionals. CINAHL, MEDLINE and Cochrane databases were searched from 1950 to 2008. In total, 40 scientific research articles in English, Swedish or Finnish related to breast-feeding counselling were included and analysed using thematic analysis. The quality of the studies was also assessed. The main barriers were deficits in knowledge, resources, counselling skills and the counsellor's negative attitude. Conflicting advice, lack of guidelines, sufficiency of counselling and perceiving of the personal education needs were examples of the indicated barriers. The most commonly described barriers in breast-feeding counselling were limitations in breast-feeding knowledge. Developing of the measurements to assess the barriers in breast-feeding counselling is needed.

Expectant fathers' and mothers' perceptions of breastfeeding and formula feeding: a focus group study in three US cities

The objective of the current study was to better understand how pregnant women and male partners conceptualize infant feeding and support for breastfeeding. Information was collected through 18 focus group interviews in 3 major US cities. There were 121 focus group participants of varying professions and income levels. Half were African American and half were Caucasian. Pregnant women and male partners had favorable attitudes toward breastfeeding, but did not articulate specific benefits to mothers or infants. Men expressed empathy for their partners' pregnancies and deferred to their partners' feeding decisions. Both groups disapproved of breastfeeding in public. Women voiced concerns about father-infant bonding more than men did. Both groups emphasized fathers' support of the infant, but not of the mother. Educators and practitioners may wish to consider expectant couples' perceptions of breastfeeding in public, knowledge of breastfeeding laws, and expectations of father-mother and father-infant relationships in their approach to breastfeeding promotion among expectant couples.

Women's perceptions and experiences of breastfeeding support: a metasynthesis

BACKGROUND

Both peer and professional support have been identified as important to the success of breastfeeding. The aim of this metasynthesis was to examine women's perceptions and experiences of breastfeeding support, either professional or peer, to illuminate the components of support that they deemed "supportive."

METHODS

The metasynthesis included studies of both formal or "created" peer and professional support for breastfeeding women but excluded studies of family or informal support. Qualitative studies were included as well as large-scale surveys if they reported the analysis of qualitative data gathered through open-ended responses. Primiparas and multiparas who initiated breastfeeding were included. Studies published in English, in peer-reviewed journals, and undertaken between January 1990 and December 2007 were included. After assessment for relevance and quality, 31 studies were included. Meta-ethnographic methods were used to identify categories and themes.

RESULTS

The metasynthesis resulted in four categories comprising 20 themes. The synthesis indicated that support for breastfeeding occurred along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as ineffective or even discouraging and counterproductive. A facilitative approach versus a reductionist approach was identified as contrasting styles of support that women experienced as helpful or unhelpful.

CONCLUSIONS

The findings emphasize the importance of person-centered communication skills and of relationships in supporting a woman to breastfeed. Organizational systems and services that facilitate continuity of caregiver, for example continuity of midwifery care or peer support models, are more likely to facilitate an authentic presence, involving supportive care and a trusting relationship with professionals.

The association between women's perceptions of professional support and problems experienced on breastfeeding cessation: a Western Australian study

A cross-sectional survey was used to determine the association among women's breastfeeding problems, their perceptions of support from midwives and child health nurses, and breastfeeding cessation in the first 10 weeks postbirth in a sample of Western Australian women (N = 2669). Primiparous women (75.8%) experienced significantly more problems that multiparous women (52.6%). Although 78.8% of all women agreed or strongly agreed that staff were helpful with feeding, 53.4% confirmed that different midwives offered different feeding advice; however, receiving different advice from midwives around feeding was not associated with breastfeeding cessation. Differences in breastfeeding cessation were associated with parity. Primiparous women's cessation was associated with experiencing any breastfeeding problems, unhelpful hospital midwives, and unhelpful information from child health nurses, whereas for multiparous women, this included 2 or more breastfeeding problems, not being able to choose when to feed, and unhelpful information from child health nurses.

Breastfeeding attitudes of Finnish parents during pregnancy

BACKGROUND

Breastfeeding attitudes are known to influence infant feeding but little information exists on the prenatal breastfeeding attitudes of parents. The purpose of this study was to describe Finnish parents' prenatal breastfeeding attitudes and their relationships with demographic characteristics.

METHODS

The electronic Breastfeeding Knowledge, Attitude and Confidence scale was developed and 172 people (123 mothers, 49 fathers) completed the study. The data were analysed using factor analysis and nonparametric methods.

RESULTS

Breastfeeding was regarded as important, but 54% of the respondents wanted both parents to feed the newborn. The mean rank values of breastfeeding attitudes differed significantly when parity, gender, education, age, breastfeeding history and level of breastfeeding knowledge were considered. The respondents who were expecting their first child, were 18-26 years old or had vocational qualifications or moderate breastfeeding knowledge had more negative feelings and were more worried about breastfeeding than respondents who had at least one child, had a higher vocational diploma or academic degree or had high levels of breastfeeding knowledge. Respondents with high levels of breastfeeding knowledge did not appear concerned about equality in feeding.

CONCLUSIONS

Both mothers and fathers found breastfeeding important. A father's eagerness to participate in their newborn's life should be included in prenatal breastfeeding counselling and ways in which to support breastfeeding discussed. Relevant information about breastfeeding should focus on the parents who are expecting their first child, those who are young, those with low levels of education or those who have gaps in breastfeeding knowledge, so that fears and negative views can be resolved.

The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars

In conjunction with other health professionals, doctors believe they play an important role in promoting breastfeeding to women. Although many have positive breastfeeding attitudes, significant knowledge deficits often limit their capacity to effectively encourage, support and assist breastfeeding women and their infants. Personal breastfeeding experience (of self or partner) may be the main source of breastfeeding knowledge and skill development and is related to improved knowledge, more positive attitudes and greater confidence. This paper describes the relationship between the cumulative length of personal breastfeeding experience and the breastfeeding knowledge and attitudes of a cohort of Australian general practice (GP) registrars, as well as their confidence and perceived effectiveness assisting breastfeeding women. The Australian Breastfeeding Knowledge and Attitude Questionnaire containing demographic items, a 20-item attitude scale and a 40-item knowledge scale was distributed between February and May 2007 to Australian GP registrars in their final year of training. Participants with more than 52-week cumulative personal (self or partner) breastfeeding experience had the highest mean knowledge score, had more positive attitudes, and were more confident and effective than all other participants. Parents with limited personal experience (<or=26 weeks) had the poorest breastfeeding attitudes and their knowledge base was similar to participants with no personal experience. Confidence and perceived effectiveness when assisting breastfeeding women rose with increasing cumulative breastfeeding experience. Personal breastfeeding experience per se does not guarantee better breastfeeding knowledge or attitudes although increasing length of experience is related to higher knowledge, attitude, confidence and perceived effectiveness scores.

A meta-synthesis of women's perceptions and experiences of breastfeeding support

BACKGROUND

Breastfeeding conveys significant health benefits to infants and mothers yet in many affluent nations breastfeeding rates continue to decline across the early months following birth. Both peer and professional support have been identified as important to the success of breastfeeding. What is not known are the key components or elements of support that are effective in increasing the duration of breastfeeding?

OBJECTIVES

The aim of this meta-synthesis was to examine women's perceptions and experiences of breastfeeding support, either professional or peer, in order to illuminate the components of support that they deem 'supportive'. A secondary aim was to describe any differences between components of Peer and Professional support.

SELECTION CRITERIA

Both primiparous and multiparous women who initiated breastfeeding were included in the study. Studies that included a specific demographic sub-group, such as adolescents, were included. Studies focused on a specific clinical sub-group, such as women post-caesarean, were not included.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

This meta-synthesis focused on maternal experiences of breastfeeding support. The meta-synthesis included both formal or 'created' peer and professional support for breastfeeding women but excluded studies of family or informal support for breastfeeding.

TYPES OF STUDIES

Primarily qualitative studies were included in the review. Studies such as large scale surveys were also included if they reported in sufficient detail the analysis of qualitative data gathered through open ended responses or included in depth interviews. Only studies published or available in English, in peer reviewed journals and undertaken between 1990 and December 2007 were included.

SEARCH STRATEGY

Key data bases were searched. The following search terms were individually added to the main keyword - breastfeeding: qualitative research, breast feeding support, peer support, professional support, postnatal support, post-natal support, volunteer support, lay support, breastfeeding counsellors, lactation consultants, social support, health education, breastfeeding education and lactation. Delimiters applied were humans, English language and years 1990-2007.

METHODOLOGICAL QUALITY

JBI-QARI (Qualitative Assessment and Review Instrument) was used to assess the quality of 38 articles selected for full review. Seven were excluded primarily because they included little qualitative data relevant to the review focus. The studies reviewed were generally of reasonable quality in terms of clarity, appropriate methodology, credibility and evidence cited to support the conclusions drawn. However, most included relatively limited discussion of theoretical or conceptual perspectives, discussion of relevant literature and reflection on the roles of the researchers.

DATA COLLECTION AND SYNTHESIS

JBI-QARI was used to manage and appraise textual data, Meta-ethnographic methods were used to develop 'interpretive explanations and understanding of breastfeeding support. Each study was systematically reviewed, reading and re-reading papers to create a list of themes through 'reciprocal translation'. Both first order and second order constructs were used to create the themes and these were then synthesised into four interpretive categories.

RESULTS

The meta-synthesis resulted in four categories comprising a total of 20 themes. The synthesis indicates that support for breastfeeding occurs along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as ineffective or even discouraging and counter productive. Second, the synthesis identified a facilitative approach, versus a reductionist approach as contrasting styles of support women experienced as helpful or unhelpful.

CONCLUSIONS

The findings of this meta-synthesis emphasise the importance of person-centred communication skills and of relationships in supporting a woman to breastfeed. Authentic presence is best supported by building a trusting relationship, demonstrating empathy, listening and being responsive to a woman's needs. Organisational systems and services that facilitate continuity of care/r and time spent with the woman, for example continuity of midwifery care or peer support models, are more likely to facilitate an authentic presence. The findings suggest the need to increase opportunities to offer women across all social groups access to peer support.

IMPLICATIONS FOR PRACTICE

The review indicates several changes in direction for practice to foster provision of support that women consider helpful and enabling, rather than disabling. These include service design that facilitates effective relationships to be established between supporters and the woman, including greater continuity of carer, Midwives need to work in service models that enable them to provide more individualised, rather than standard care and advice, to spend time and provide practical help to those women who need it. Antenatal education needs to be more learner-centred, using pedagogic models based on adult-learning principles, and should provide women with information that is realistic, detailed and positively encouraging. Midwifery education needs to integrate sufficient focus on developing midwives' communication and information giving skills. Schemes to offer peer support should be developed further, using a pro-active approach, including home visits and support groups.

IMPLICATIONS FOR RESEARCH

Further research is warranted on schemes to develop peer models of support. Research is also needed to investigate in more depth the service models and conditions that are conducive to midwives' ability to offer effective support for breastfeeding.

Skin-to-skin contact for culturally diverse women having breastfeeding difficulties during early postpartum

BACKGROUND

Early breastfeeding (BF) cessation is more common in black women and women who experience BF difficulties during early postpartum. Skin-to-skin contact (SSC) during early postpartum promotes and sustains BF. The focus of this secondary analysis is on BF status and maternal race/ethnicity.

METHODS

Data were collected in a prospective exploratory study with 48 healthy and culturally diverse mother-full-term infant dyads. These dyads were selected because they were experiencing BF difficulties postbirth (mean, 16.9 hours). Following informed consent, the SSC intervention was given with four BFs: the next three after enrollment plus one before hospital discharge. BF status (duration and exclusivity) was measured using a six-category instrument, the Index of Breastfeeding Status, at hospital discharge and by telephone interview 1 week and 1 month later.

RESULTS

BF status was generally similar in this culturally diverse sample, except that at 1 month black mothers had lower exclusive BF (33%) and higher BF cessation (46.7%). These mothers were all high risk for poor BF outcomes, with black mothers at highest risk. Even so, BF outcomes exceeded those in studies that included all BF mothers whether or not they were having difficulties.

CONCLUSIONS

Based on these findings, we propose that this SSC BF intervention, provided in hospital in a time-sensitive manner by a warm perceptive person, can transcend the likelihood of early BF cessation for most mothers regardless of race/ethnicity.

Supporting breastfeeding mothers: qualitative synthesis

AIM

This paper is a report of a synthesis of mothers' and healthcare professionals' experiences and perceptions of breastfeeding support.

BACKGROUND

Despite increasing knowledge, breastfeeding rates remain relatively static and mothers continue to report dissatisfaction with their experiences of breastfeeding. Greater understanding of breastfeeding may be achieved through rigorous qualitative research, and there has been a recent increase in such studies.

DATA SOURCES

Electronic databases and citation lists of published papers were searched for articles listed between 1990 and 2005 and updated in May 2007. Studies were included if they used qualitative methods, were published in English, explored an aspect of breastfeeding and were based in a westernized country.

REVIEW METHODS

Papers were included if they reported studies using qualitative methods to explore breastfeeding and were published in English and based in a westernized country. Each study was reviewed and assessed independently, key themes extracted and grouped, and secondary thematic analysis used to explore key concepts.

RESULTS

From the 1990-2005 search, five themes emerged in health service support of breastfeeding: the mother-health professional relationship, skilled help, pressures of time, medicalization of breastfeeding and the ward as a public place. Social support had two themes: compatible and incompatible support. One additional theme emerged from the update to 2007: health professional relationships.

CONCLUSION

Mothers tended to rate social support as more important than health service support. Health service support was described unfavourably with emphasis on time pressures, lack of availability of healthcare professionals or guidance, promotion of unhelpful practices and conflicting advice. Changes are required within the health services to address the needs of both mothers and staff.

Critical views on postpartum care expressed by new mothers

BACKGROUND

Women's evaluation of hospital postpartum care has consistently been more negative than their assessment of other types of maternity care. The need to further explore what is wrong with postpartum care, in order to stimulate changes and improvements, has been stressed. The principal aim of this study was to describe women's negative experiences of hospital postpartum care, expressed in their own words. Characteristics of the women who spontaneously gave negative comments about postpartum care were compared with those who did not.

METHODS

Data were taken from a population-based prospective longitudinal study of 2783 Swedish-speaking women surveyed at three time points: in early pregnancy, at two months, and at one year postpartum. At the end of the two follow-up questionnaires, women were asked to add any comment they wished. Content analysis of their statements was performed.

RESULTS

Altogether 150 women gave negative comments about postpartum care, and this sample was largely representative of the total population-based cohort. The women gave a diverse and detailed description of their experiences, for instance about lack of opportunity to rest and recover, difficulty in getting individualised information and breastfeeding support, and appropriate symptom management. The different statements were summarised in six categories: organisation and environment, staff attitudes and behaviour, breastfeeding support, information, the role of the father and attention to the mother.

CONCLUSION

The findings of this study underline the need to further discuss and specify the aims of postpartum care. The challenge of providing high-quality follow-up after childbirth is discussed in the light of a development characterised by a continuous reduction in the length of hospital stay, in combination with increasing public demands for information and individualised care.

Evaluating multi-dimensional aspects of postnatal hospital care

OBJECTIVES

to investigate women's experiences of postnatal hospital care in relation to four different aspects: (1) interpersonal care; (2) time spent on physical check-ups; (3) time spent on information and support; and (4) time spent on assistance with breast feeding. More specifically, we aimed to establish whether typical clusters of women could be identified, and if so, whether these clusters could be related to specific outcomes of care, to the way in which care is organised, and to the individual's psychological health and socio-demographic background.

DESIGN

longitudinal population-based survey, including three questionnaires completed in early pregnancy, at 2 months and 1 year after birth.

SETTING

all postnatal wards in Sweden.

PARTICIPANTS

women (n=2338) recruited at their first booking visit at 593 antenatal clinics, who responded to questions relating to postnatal hospital care 2 months after birth.

FINDINGS

eight cluster profiles defined by the four aspects of postnatal care were identified. About half of the women were found in clusters that were satisfied with most aspects of care, and half in clusters that were dissatisfied with one aspect or more. Only 32% were very satisfied with all four dimensions. Specific groups of women, such as first-time mothers, migrants, young mothers and those with a short length of stay, were dissatisfied with different assessments of postnatal care. Psychological health in early pregnancy was associated with high ratings of all aspects of care, whereas emergency caesarean section and instrumental vaginal delivery was associated with dissatisfaction with breast feeding support and time spent on health check-ups.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

women's individual appraisal of specific aspects of hospital postnatal care could be grouped into response patterns that were shared by smaller or larger groups. These patterns were related to maternal characteristics, labour outcomes and the way in which care was organised. The multi-faceted approach used in this study provided details about who was dissatisfied with what, and showed that women are not necessarily either satisfied or dissatisfied with care in a general sense. In order to provide individualised care, the carer needs to be aware of these differences.