The role of the midwife in breastfeeding is extensive and includes relaying knowledge about the subject, promoting, encouraging and supporting breastfeeding mothers, complying with policies and practices, and importantly, practising in a professional manner. Although at first glance these aspects of the role appear simple and straightforward, when considered in more depth, this is often not the case. There are inherent problems associated with all the above aspects of the role because of the competing paradigms, ideals or models affiliated to breastfeeding. This article will examine each of the above aspects of the midwives role and discuss suggestions for the way forward.
The dichotomies and dissonances associated with the midwives' role in breastfeeding became evident when undertaking a study in 2006 looking at midwives' experiences of breastfeeding on a personal, educational and professional level. In the study 12 midwives were interviewed from a small maternity unit in Nottinghamshire. From these interviews, a questionnaire was formulated and 711 where distributed to six maternity units in the North of England. Four hundred and ten questionnaires were returned giving a response rate of 57.8% (Battersby, 2006). Some of the findings from this study will be incorporated within this paper to enhance the discussion.
Educational conflicts
Educational conflicts arise from how midwives acquire their knowledge of breastfeeding and there are many different roots including:
There are consequences associated with how knowledge is gained. For midwives, acquired knowledge will have been gained through midwifery education, both pre- and post-qualification. This type of knowledge, which is often obtained through research and referred to as evidence-based, is that which is regarded by many as the ‘expert's’ knowledge or authoritative knowledge. Wickham (2004) claims that the cultural and medical context in which English midwifery sits values scientific knowledge above all others.
Acquired knowledge however, can disempower breastfeeding women because it views the breastfeeding process as identical for all women and perpetuates the Cartesian view of the body as a machine (Martin, 1989). This view also advocates a ‘one remedy solves all problems’ approach which midwives know isn't true from their experiences of breastfeeding. From practical experience it is evident that what helps one mother may not help another.
Culturally and socially absorbed knowledge, experiential/embodied knowledge and shared knowledge are often disregarded as being subjective and unreliable, and consequently many midwives may discard them because of their acquired knowledge. Personal and emotional experiences however, are major ways of learning about breastfeeding for many women.
Dissonance and breastfeeding promotion
Health promotion is an integral part of the midwives' role and midwives should promote practices which will enhance the health of both the mother and her infant. The health benefits of breastfeeding cannot be disputed but dissonance in promoting breastfeeding has become more prevalent in recent years and particularly with the advent of the Baby Friendly Initiative (Battersby, 2006; Furber and Thomson, 2008). There is a conflict of policies versus informed choice within the role of the midwife, particularly relating to women who had chosen to formula feed their infants. In Battersby (2006), midwives related in the study how they felt they should be promoting breastfeeding to all mothers because of their hospital policies but believed this was difficult to do if a mother had expressed a desire to formula feed her infant. They felt they were undermining the woman's choice.
Whose choice
For the last 20 years there has been an increasing emphasis on women having choice and control within maternity care (Department of Health (DH), 1993). This means providing unbiased information to allow women to make choices about their care and placing the needs of the woman at the centre her care. However, there are only certain ‘choices’ that are sanctioned by midwives and health professionals, and breastfeeding falls into this remit whilst bottle-feeding does not (Anderson, 2002). Midwives are expected to support wholeheartedly women who wish to breastfeed but are encouraged to change women's wishes and choices if they want to formula feed. Thus two diametrically opposed duties of midwives can result in dissonance and conflict for midwives.
Battersby (2006) found that some midwives were hesitant to inform women fully of the benefits as breastfeeding because of the ‘fear of offending women or appearing to be forcing breastfeeding’ (Midwife 133). Discussing breastfeeding with a woman who had decided to bottle-feed was not perceived as a positive step by other midwives, who felt, as Midwife 220 did, that it could make women hostile towards midwives while others viewed it as coercion. These comments are distressing because it is not the discussion of breastfeeding that is problematic but rather the manner in which it is done. Rapley (2001) clarifies this by saying communication skills (or lack of them) determine whether mothers feel pressured to breastfeed or empowered to make an informed choice. Additionally, Minchin (2000) believes that informed choice becomes ‘a joke’ because although parents are bombarded with the benefits of breastfeeding they are rarely presented with the truth about the risks of infant formula.
Conflicts when supporting breastfeeding mothers
Breastfeeding and time
Helping a new mother to initiate breastfeeding can be time consuming, but help in the early stages is essential to give the mother and baby a good start and can make all the difference to a mother successfully breastfeeding her infant. Competing demands on midwives time is often a major issue when supporting breastfeeding mothers (Battersby, 2006; Dykes, 2009). In Battersby (2006) midwives reported that they frequently felt that the needs of the institution overrode the time they could spend with breastfeeding mothers. This created a strain between complying with the demands of the institution and the ethos of being in a caring profession.
The provision of maternity care has changed considerably over the last decade. The throughput of mothers has increased as maternity care has been rationalised, hospitals have closed or merged and fewer maternity units are caring for the same number of mothers (Coyle, 2012; Donnelly and Santry, 2012). Additionally, birth rates have risen in recent years placing further strain on the maternity services (Royal College of Midwives (RCM), 2012). The workload is unpredictable and subject to surges in demand. The documentation of care is essential in an era of increasing litigation and can take priority over client care. In some areas, recruitment of new staff has been curtailed because of the increasing costs associated with the NHS (RCM, 2012). All these issues increase the workload of the midwife and place her in a position where she has competing demands on her time which may limit the help and assistance she can provide to a new mother who is initiating breastfeeding.
Consequences of lack of time and competing demands
Competing demands on the labour ward may result in a restriction of time for the mother and baby to initiate breastfeeding before being transferred to the postnatal ward (Battersby, 2006). Although Battersby (2006) found that the majority of midwives in the survey believed in the benefits of skin-to-skin, it was not always implemented because the labour ward was too busy. Many midwives commented that when the labour ward was busy, assisting a mother to breastfeed was not considered a priority.
On the postnatal wards, 77.2% of midwives found that their breastfeeding support was conditional on other competing priorities, such as; telephone calls, emergencies, other mothers, documentation. Breastfeeding mothers were seen by some midwives as the winners when competing against bottle-feeding mothers for their time (Battersby, 2006). When time is rationed the patients will need to vie for time from their health professionals (Lipsky, 1980) but whether it is bottle-feeding or breastfeeding mothers who are disadvantaged is debatable.
Dykes (2004) presents an insight into how time is taken away from midwives and mothers within an institutional setting and the negative effect this has on the support midwives give to breastfeeding mothers. The study highlights the way in which midwives work and communicate can be a reflection of the ongoing pressures created by linear time constraints and the unpredictability of the situation, referring to the ‘tyranny of time’ (Dykes, 2004: 168).
How to find time?
The National Institute for Health and Care Excellence (NICE) guidelines (2006) recommend that the issue of time is urgently addressed so midwives can provide time to support breastfeeding mothers. This is a tall order in today's climate of cost-cutting and rationalisation of services. This may mean that the support of breastfeeding is delegated to others. This is already happening in some institutions and communities (Dykes, 2003; MacArthur et al, 2009).
Breastfeeding peer support has flourished in the UK as it can provide excellent support for mothers that midwives can't provide due to time constraints and is advocated as a way forward by the DH (2004). Breastfeeding peer supporters can work both in the hospital environment or in the community setting. Some work as paid supporters whereas others are volunteers. However, they too have been affected by monetary constraints and in some areas the numbers have been reduced or absorbed into other roles.
Dichotomies between evidence-based practice and experiential/personal experiences
Differences have been encountered between evidence-based practice and experiential/personal experiences resulted in dilemmas for some midwives (Battersby, 2006).
In order to offer better support and reduce conflicting advice, many maternity units have introduced infant-feeding policies and infant-feeding coordinators. The policies are usually based on the evidence provided by the World Health Organization (1998) which uses, as far as possible, only randomised controlled trials for their evidence (acquired knowledge).
Within the 2006 study, reservations were expressed regarding hospital policies. Many midwives agreed with the need for a policy to improve the standard of care but sometimes had difficulty accepting the evidence-base for the policy, the way it was being implemented or the lack of autonomy it gave them when caring for women as individuals (Battersby, 2006; Furber and Thomson, 2008). Midwives resistance to breastfeeding policies can result in the perpetuation of practices known to be detrimental to breastfeeding.
Both the midwives and mothers said that supplementary or top-up feeds, which has been strongly associated with mothers' discontinuing breastfeeding, was still routinely practiced (Battersby, 2006) and the rates within the study were higher than nationally with 41% of babies in the study sites receiving top-up compared to 31%, nationally (McAndrew et al, 2012). The variance in the rates could be associated with the difference in time of data collection but Hamlyn et al (2002) found a rate of 28% in the National 2000 Infant Feeding Survey. Interestingly, very few midwives said they gave top-ups but all knew some who did.
Another area that midwives found difficulty in complying with was the use of nipple shields. Their use has been strongly discouraged on the grounds that they can further irritate an already sore nipple (Henschel and Inch, 1996), reduce milk production (Woolridge et al, 1980), and result in a baby rejecting the breast (RCM, 2002). However, Wilson-Clay (1996) argues that their judicious use can salvage breastfeeding. Within the 2006 study, 72.5% of midwives believed that nipple shields had a place and three themes emerged from the midwives' comments. First, midwives were being prevented from using their own initiative; second was the lack of recent research to support or refute their use, and finally the midwives were using their own experience as a basis for practice (Battersby, 2006).
Conceptualisation of breastfeeding
Dichotomies between evidence-based practice and experiential/personal experience can arise because of the midwives' conceptualisation of breastfeeding. Most midwives within the study (Battersby, 2006) believed that breastfeeding is the natural thing to do but when examining the ‘Naturalness of breastfeeding’ two competing paradigms or views emerged.
First, breastfeeding is seen as culturally normal. Although whether this is in fact true in England, is debatable. In the 2010 Infant Feeding Survey (McAndrew et al, 2012) there was an initiation rate of 81% at birth but this rapidly dropped off so that at 1 week, less than half of all mothers (46%) were exclusively breastfeeding, and this had fallen to around a quarter (23%) by 6 weeks. This indicates that the majority of mothers use formula from an early stage.
The ‘biologically naturalness’ of breastfeeding is the second concept. This appertains to the physiological basis of breastfeeding, which is that humans are designed to breastfeed and therefore should do so. This view highlights the nutritional component of breastfeeding and ignores social and cultural aspects of infant feeding.
Apparent tensions
Many midwives found a tension between the ‘naturalness’ of breastfeeding and their perception of the reality of breastfeeding as a difficult and problematic process (Battersby, 2006).
There were many midwife–mothers in the study and a high proportion of them had personal experiences of breastfeeding.
The midwives' personal experience
Very few midwives in the study talked about being successful at breastfeeding and this may be because as midwives they had higher expectations of themselves to succeed. This was evident in the profound feelings some midwives felt when they did not breastfeed for as long as they had planned. It could also be linked to the midwives perceptions that breastfeeding was the social norm for them but not for society as a whole. Their professional knowledge of the benefits of breastfeeding could also have been a motivational force (Battersby, 2006).
Midwives feelings of guilt
The feelings of failure and guilt featured prominently in the midwives narratives of breastfeeding. What was particularly poignant was that midwives who failed to breastfeed for as long as they intended often felt a failure not only as mothers but as midwives (Battersby, 2006). For example, one midwife said: ‘I lost all confidence as a mother and a midwife when I failed at the most natural thing in the world.’ (Midwife 69).
Even midwives who had enjoyed breastfeeding still felt guilty when discontinuing and the feelings of failure and guilt were long-lasting for some of the midwives.
Influence of personal experiences on practice
Personal experiences can influence midwives practice. Midwives in the 2006 study had a diversity of breastfeeding experiences, both positive and negative, and some of the midwives recalled how they used their experiences within the professional arena (Battersby, 2006). This finding has also been observed in other studies. Furber and Thompson (2008) acknowledge that personal experiences may have influenced the midwives responses in their study, while Hellings and Howes (2004) found that paediatric nurse practitioners in the USA identified that their own breastfeeding experiences were a valuable source of knowledge when caring for others. Jamieson (1997) warns that a professional who has had a bad experience of breastfeeding, either personally or professionally, may engender negative attitudes towards breastfeeding and this attitude will be especially powerful.
Positive breastfeeding experiences
In Battersby (2006), a small minority experienced no problems breastfeeding and subsequently found it difficult to deal with mothers who did. This was explained in their comments: ‘Because I had relatively few problems I suppose I do struggle sometimes with understanding why some people encounter so many problems.’ (Midwife 543) (Battersby, 2006).
Negative experiences
Negative experiences can have a profound effect on a midwife's practice as well as personally. A midwife who had a negative experience of breastfeeding related how when she: ‘…initially returned to work I felt breastfeeding was too difficult and found advising women without being cynical difficult’. (Midwife 21) (Battersby, 2006).
Using their own experiences in practice
Some midwives use their own experiences to inform mothers. For example, in Battersby (2006) one midwife stated that when helping breastfeeding mothers she recalled her own experience saying: ‘We are teaching the mums if possible you have to get babies to the breast in the first hour after delivery, possibly the first half hour, because that's when they are most awake and looking round and I look back now and she [her own baby] didn't feed for 24 hours but we successfully breastfed. When she got rid of the mucous, she was fine. So I try to tell other mums this. If they don't want to breastfeed in the first hour it isn't a problem, they can be left because I think for some mums they can get anxieties.’ (Midwife 3).
Another example of midwives using their own experiences in practice was given by a midwife, who had bottle-fed her own children, and appeared to use her personal experience to try to reduce a mother's guilt at changing from breast to bottle-feeding. The mother explained how the midwife told her: ‘look if you can't do it, don't worry. My two have both been bottle-fed and they've been fine.’ (Midwife 34) (Battersby, 2006).
Why do midwives use their personal experiences?
It is important to examine why, as professionals, midwives use their own personal experiences in practice. There are several different theories for this; the midwives' personal experience may be influential (Finigan, 2004), the experience may have had a major impact on her own life and she believes that telling mothers of this experience may be helpful to them.
Cloherty et al (2004) found a further three reasons why midwives gave top-ups. First, the midwives may be acting in an altruistic manner thinking they are protecting mothers from tiredness and distress—by giving the baby a bottle the mother will get a good nights rest and then be able to continue to breastfeed successfully. Second, the midwife may also be trying to making it easy for mothers to give up breastfeeding. When a midwife says that her own children have not experienced problems because of bottle feeding, it can give permission to mothers to do the same. The final reason is that the midwife may be protecting the mothers from guilt. They are saying it happened to me and I'm a midwife so don't feel guilty if it also happens to you.
How can midwives overcome conflicts in their role?
There are several ways to attempt to eradicate the conflicts between acquired, instinctive and experiential knowledge and policy experience:
Gaining more knowledge
Improving knowledge-base of breastfeeding and recognising that there are different types of knowledge could be the first step to eradicating this conflict. The appropriate use of both embodied and experiential knowledge can assist in recognising the individual needs of breastfeeding mothers. A professional manner should be adopted at all times, and consideration should be taken over what is appropriate to tell mothers of personal experiences.
Increasing knowledge-base will also help to understand the underpinning evidence for breastfeeding policies. By actively participating in the development of policies, midwives are much more likely to take ownership and comply with its content.
Supporting mothers through good communications
The importance of good communication in the supporting of breastfeeding mothers and promoting breastfeeding can not be over-stressed. UNICEF (2013) highlight that certain types of communications are more likely to help women to feel supported, self-confident and enabled to continue to breastfeed:
It is important to recognise that the type of communications used should not create pressure on women, making them feel inadequate or failures (UNICEF, 2013).
Reflection on personal experiences
Reflecting on personal experiences should be integral to midwifery practice. Breastfeeding counsellors for the National Childbirth Trust and La Leche League undergo a personal debriefing at the commencement of their training. The need for midwives to recognise and acknowledge their feelings is imperative. Friere (1981) argues that when emotion, rather than critical reflection, is the basis for radical action, the understanding of power can be distorted in mythical and illogical ways. Therefore a midwife who has unresolved issues related to her breastfeeding experience may reflect those feelings in practice. Palmer and Kemp (1996) state that midwives with strong guilt feelings may go into denial as a natural survival process which may result in them becoming hostile or dismissive towards breastfeeding. Both personal feelings and perceptions of breastfeeding should be explored and the underlying philosophy addressed in order to reflect on how this may also affect the care provided.
Conclusion
It could be perceived that the midwife has to ‘straddle the line’ when undertaking her duties towards breastfeeding. This is because the midwives' role in breastfeeding, although at first seems straight forward, is fraught with complexities. This article has presented issues as a source for dichotomous thought to encourage reflection of the various perspectives and how they may impinge on professional practice.
There is a conflict between the different ways of knowing, their embodied knowledge versus authoritative knowledge, which is then compounded by time constraints and national policy related to maternity care. The concept of woman-centred care and the emergence of new knowledge combined with personal experience of breastfeeding make the process more multifaceted. These issues need to be addressed on an individual and national basis to enable midwives to more appropriately fulfil their role to breastfeeding mothers.