In this article, I will critically reflect on an encounter with a breastfeeding woman and her husband that highlights issues of partner support, cultural influences and, in light of these, meaningful and effective communication. The appointment took place during my second year as a student midwife. Reflecting on this has helped to develop my competency in standard 4.1 of the Nursing and Midwifery Council (NMC) Standards for pre-registration midwifery education:
‘Women can expect a newly registered midwife to understand and share information that is clear, accurate and meaningful at a level which women, their partners and family can understand.’
This is also in keeping with the continued emphasis from UK maternity services on the importance of partner involvement in care (Royal College of Midwives (RCM), 2011). Reflection is the systematic re-examination of experience, which aims to promote personal and professional development, whether through diary writing, verbal discourse, or formal written reflection (Persson et al, 2015; Bzowyckyj et al, 2017). For the purposes of this article, Gibbs' iterative model (1988) has been used as an appropriate tool to reflect on this experience (Bulman and Schultz, 2013). Pseudonyms will be used throughout the article to refer to those involved to maintain confidentiality (NMC, 2015). The woman in our care will be referred to as Adebola and her partner as Ali. Both Adebola and Ali gave informed consent for their experience to be shared.
Description
I met Adebola and Ali, recent immigrants from Nigeria, while undertaking a day 10 postnatal visit with my mentor in the community. On arrival, Ali greeted us. He began asking our advice on supplementing the baby with formula, as he felt they required more quantity and variety of milk. He explained that Adebola had been exclusively breastfeeding, but he came from a culture whereby mixed formula and breastfeeding was the social norm (Agho et al, 2011). In response, my mentor and I began discussing the advantages and disadvantages of this feeding method calmly and openly. However, when Adebola joined us, she voiced her disagreement with Ali and attempted to shut down the discussion, reportedly feeling pressurised by her husband to transition to mixed feeding. My mentor and I weighed the baby with parental consent, to reassure both parents, but even after establishing that there was no clinical indication for supplementation, Ali did not seem convinced. Keen to advocate for exclusive breastfeeding, as well as Adebola's choice, we continued to speak at greater length, but as we did so, Ali became more insular and withdrawn, eventually nodding in submission.
Feelings
Initially, I was pleased that Ali had the confidence to speak openly to us about his concerns, and that he respected the knowledge and expertise of the midwifery profession. Yet on Adebola's return, these feelings quickly turned to frustration and irritation at the pressure he placed on her, and the discord this had caused. It seemed that Ali's thoughts regarding feeding method could have potentially adverse effects on Adebola's choice, their relationship, or Adebola's overall perception of family support. Although I felt immensely proud of Adebola's conviction to exclusively breastfeed despite this pressure, I was anxious that this couple's opposing views would negatively impact their relationship or feeding choices. As the conversation developed, I began to feel uneasy about my role: I was no longer student midwife imparting breastfeeding knowledge, but a mediator attempting to solve a marital dispute.
As a consequence, I felt pressure and eagerness in equal measures. I recognised that this conversation could be formative for this family's decision, and was also keen to impress my mentor with my handling of such a delicate situation. Talking with confidence, I used the knowledge and skills I had acquired over the past year. However, as Ali's demeanour changed and he became more closed, I realised, with regret, that my recommendations had become too forceful. Despite my initial optimism about the information I was sharing, I sensed my that my delivery had neither united nor reassured either parent. Communication had broken down, and I left feeling confused and frustrated about when this had happened, and what I could have done to prevent it.
Evaluation
Initially, the communication between Ali and I was open, reciprocal and friendly, which enabled us to explore his familial and cultural background. Ali initially found the ‘back to basics’ approach of the information we gave helpful, indicated by positive verbal and non-verbal cues (Kourkouta and Papathanasiou, 2014). Ali made himself vulnerable by sharing his cultural background and personal standpoint, and my mentor and I respected this, gradually unpacking his concerns. We spent a lot of time talking to Ali individually, which enabled this openness, and as the last appointment of the day, there was little time pressure that could have rushed this conversation.
However, after observing Adebola's fierce rebuttal of her husband, the tone changed. Her presence added a more hostile dynamic, and my sense of duty to advocate for Adebola overtook and undermined the openness I had built with Ali, shifting communication from reciprocal sharing to one-sided teaching. Although the information I shared was still evidence-based and in line with national guidance, the tone of the conversation became more emotionally charged, and I began to prioritise Adebola's choice, to the exclusion of her husband.
By the time we left, no resolution had been attempted and the follow-up plan remained unchanged. To my mentor, it seemed that Adebola's conviction alone would enable her to continue to exclusively breastfeed, but I left with a deep sense of unease. I had allowed the pressure being exacted on Adebola to frustrate me, which had interrupted communication from both sides.
Analysis
Adebola is one of the 74% of women in the UK whose child receives breastmilk as a first feed (NHS Digital, 2017), but statistics from Public Health England (2018) report that this figure falls to 44% by 6 weeks, and continues on a downward trajectory. Although exact figures vary according to region, maternal disclosure and category definitions, the general trend of exclusive breastfeeding rates is undisputed. Influencing factors can generally be divided into four subcategories: demographic, biological, social and psychological (Thulier and Mercer, 2009). In general, infant feeding decisions are made before contact with health professionals (Radzyminski and Callister, 2016), suggesting the influence of external factors. Although some of these are not amendable by midwives, knowledge of these factors would have provided my mentor and I with a deeper understanding of women's choices and the pressures that accompany them, creating more effective communication overall. In Adebola's case, two of these factors worked in her favour, and two had the potential to limit her. Psychologically and biologically, Adebola was in a strong position: she had sufficient milk supply, a healthy body mass index (BMI), no history of smoking or drinking alcohol, and had a spontaneous vaginal birth (Pilla and Kitsantas, 2017). She also had intention, interest and confidence in her ability to breastfeed (Meedya et al, 2010).
Socially, however, Adebola did not have the support of her partner, and my underestimation of his influence meant that we failed to relieve the pressure, although it was coming from a place of concern. My mentor and I discussed his opinions and background, but neither of us fully appreciated the effect this might have on Adebola's infant feeding decisions. In advocating exclusively for Adebola, we alienated Ali, and our communication was no longer ‘meaningful, at a level at which […] partners […] can understand’ (NMC, 2009: 53).
Although infant feeding decisions are entirely a woman's choice (Department of Health, 2009), in reality, partner support—or lack thereof—is a major cause of attrition in breastfeeding. A cohort study by Scott et al (2006) demonstrated a positive association between breastfeeding continuation and the partner's knowledge, attitudes and support. Similarly, a qualitative study (Mannion et al, 2013) evaluated maternal confidence and ability to breastfeed using the breastfeeding self-efficacy scale. The authors found that, after controlling for previous breastfeeding experience and age of infant, those who reported active or positive support from their partners scored higher than those who reported ambivalent or negative support. Although Ali may have perceived his intervention as ‘active support’, his attitudes were beginning to lead to relationship distress, which can also hinder breastfeeding (Sipsma et al, 2013).
One study (Persad and Mersinger, 2008) suggested that partner and family support were more vital than personal attitudes and beliefs, although many participants in this research were young and still lived with family members, and were therefore more likely to place a higher value on their social network. Many studies have reported a causative relationship between partner support and breastfeeding duration (Pisacane et al, 2005; Scott et al, 2006; Rollins et al, 2016). Arora et al (2000) found that a mother's perception of their partner's attitude was the number one reason women transitioned to bottle-feeding (Figure 1). Actively involving partners in infant feeding discussions therefore acknowledges this influence and uses it to empower both parents, unite couples, promote exclusive breastfeeding, and affect long-term childhood outcomes (Belfort et al, 2013).
Research such as this has supported policies to increase the inclusion of partners in maternity care (RCM, 2011). By doing so, women can have better experiences during labour (Karlström et al, 2015), families are more likely to make positive lifestyle changes (Fieril et al, 2017), and partners are more likely to encourage women to breastfeed (Rollins et al, 2016). The level of partner support that women receive seems to correlate with increased partner involvement in antenatal care. Indeed, interventions that have specifically targeted partners have dramatically improved initiation and duration rates of breastfeeding (Rollins et al, 2016). Partners are clearly instrumental in influencing the health choices made by women, so maternity care providers' responsibility to ensure partners feel involved, reassured, and prepared. This is why the NMC standards include ‘partners and families’ (NMC, 2009), and Ali and Adebola serve as an example of how crucial this inclusion can be.
This experience allowed me to reflect on how breastfeeding is a highly culturally specific behaviour. Adebola belongs to the 33.5% of native Nigerian women who choose to exclusively breastfeed, resisting the majority trend of women from the same ethnicity (Onah et al, 2014), who choose mixed feeding. According to this study, this is due in part to pressure from relatives and communities to supplement (Onah et al, 2014). Of the women surveyed, 21.8% said they would not practice exclusive breastfeeding even if all conditions were favourable. This is perhaps why a survey conducted by the National Population Commission (NPC) and ICF International (2014) in Nigeria found that only 7.1% of infants were being exclusively breastfed at 5 months, despite 54.4% of Nigerian people living below the poverty line (UNICEF, 2013). Supplementation for non-clinical reasons is therefore common in parts of Nigeria, with one survey estimating that 75% of babies under 6 months are supplemented, whether with formula milk, water, or other complimentary foods (NPC and ICF International, 2014), partly due to perceived lack of dietary diversity (World Health Organization, 2010).
Black African women living in the UK tend to have higher rates of exclusive breastfeeding and breastfeeding initiation (Agboado et al, 2010; NHS Digital, 2012). However, migrant black African women—that is, women born abroad and intending to stay in the UK for more than 1 year (UN General Assembly, 2018)—tend to have significantly lower rates (Dowling et al, 2018). In 2015, 13.3% of the UK were born abroad (Office for National Statistics, 2016), so significant numbers of women, like Adebola, accessing NHS care will part of this more vulnerable population. The reasons behind this trend are complex and unclear, but may relate to lack of breastfeeding education, low pay and high housing and childcare costs that prevent women from leaving the house and accessing wider social support (Downing et al, 2018). Although exact figures differ, the general trend among migrant black African women in the UK appears to be one of precipitous breastfeeding cessation and increasing supplementation.
From our conversation with Ali, he appeared to be influenced by this background, which was indicated by his intrinsic discomfort with Adebola exclusively breastfeeding, despite our reassurances to the contrary. The UK is also subject to aggressive marketing of formula milk, which has normalised supplementation (Rollins et al, 2016), with online formula sales showing growth of 44% between 2013-14 (The Nielsen Company, 2015).
Examining the importance of partner support and cultural influences has allowed me to explore the breakdown in communication. Midwives are trained to be ‘advocates for women’ (Finlay and Sandall, 2009), but this role can be falsely construed as communication with the woman alone. I failed to fully recognise the importance of Ali's position and background (England and Morgan, 2012), and our communication changed from a reciprocal partnership to an expert-recipient relationship, which may have made Ali feel undermined and embarrassed (Wright and Geraghty, 2017). Studies have found that communication between health professionals and their families goes beyond the simple transmission of information; it involves the transmission of feelings, and letting families know that they have been acknowledged (O'Hagen et al, 2014). In this case, we failed to adequately show Ali that we acknowledged his point of view, which served only to alienate him from the discussion, and create distance between him and Adebola.
Conclusion and action plan
Although exclusive breastfeeding is encouraged in local and national guidelines (National Institute for Health and Care Excellence, 2015; Guy's and St Thomas' NHS Foundation Trust, 2016), few documents emphasise the role that partners have to play in infant feeding choices. Reflecting with my mentor and peers has helped to shape my future practice (Johns, 2009). Debriefing has helped to focus my thoughts on specific and achievable goals for improvement relating to meaningful communication and partner involvement (MacLeod, 2014).
In the future, I will ensure my communication is more inclusive of partners and other family members. To achieve this, I will take additional care to use non-verbal communication skills that often serve to express warmth, respect and sincerity (McCabe, 2004). I will assume that families will intrinsically trust health professionals, but will instead aim to build trust slowly through open ended questions. I will aim to have a stronger appreciation of the cultural factors that may influence couples, and use this to inform my discussions. Mindful that relationship distress can be a factor in breastfeeding cessation (Sipsma et al, 2013), I will aim to address both parents together, focusing on the factors that unite them. I will allocate more time, or another follow-up visit, for families who disagree in infant feeding discussions. I will also ensure that infant feeding discussions take place antenatally, ideally with both parents, capitalising on a time in which parents are particularly receptive to health messages.
In a culture steeped in emotionally charged rhetoric surrounding infant feeding, the midwife is well placed to give accurate, non-judgemental, evidence-based information. My experience has highlighted the role of the midwife as an advocate for the whole family, not just the mother. In the words of Day-Stirk (2002), ‘the birth of a baby is the birth of a family’.