Breastfeeding is accepted as the optimum way to nourish babies (World Health Organization (WHO), 2016), with proven health benefits for both babies and mothers (Renfrew et al, 2012; Victora et al, 2016). One of the global nutrition targets for 2025 (WHO, 2014) is to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% of mother–baby dyads; the current rate is 36% (WHO, 2016).
In the UK, it has been estimated that even a moderate increase in the rate of exclusive breastfeeding could save the NHS £40 million, due to the reduction in a number of key maternal and infant illnesses (Renfrew et al, 2012). In a time of ongoing budget cuts in the health service, this is significant, particularly as the true cost-saving that could be gained from an increase in exclusive breastfeeding rates is likely to be considerably higher (Renfrew et al, 2012).
In the UK, the promotion of breastfeeding has been part of public health policy for some time, and there has been an increase in initiation rates from 76% in 2005 to 81% in 2010 (McAndrew et al, 2012). This increase in breastfeeding is not sustained in the long term, with the rate falling to 69% within 1 week, and 55% at 6 weeks. Of particular interest is the initial drop-off in breastfeeding, as this is the time during which midwives are the key providers of care for women.
It has long been established that women want practical, informed support regarding infant feeding (Graffy and Taylor, 2005; Nelson, 2006). However, the findings of the Infant Feeding Survey 2010 suggest that whatever support women are receiving has not been effective in prolonging breastfeeding (McAndrew et al, 2012). A recent survey by the Royal College of Midwives (RCM) found that 55% of mothers who responded said that they received little or no support with breastfeeding from midwives, while 57% of the midwives who responded said they would like to be more involved in supporting breastfeeding (RCM, 2014).
Interactions between women and midwives are complicated and diverse, and are often influenced by outside factors such as busy wards (Dykes, 2005; Bäckström et al, 2010; Schmied et al, 2011). A large body of research has been undertaken focusing on breastfeeding, but in general the focus has been on the effects on women and babies, or women's experiences. Midwives' experiences have largely been unexplored, and when they have been examined it has been directly in relation to the care they give women (Furber and Thomson, 2006; 2008a; 2008b). Any potential impact that these encounters have had on the midwives involved has not been explored in depth.
Methods
Study aim and design
The aim of this study was to explore midwives' experiences of helping women who were struggling to breastfeed. A qualitative methodology informed by descriptive phenomenology was used, with semi-structured interviews being conducted to discuss midwives' experiences regarding breastfeeding support. The study was carried out in a Trust in the South East of England, which serves a predominantly professional population but with some areas of deprivation. The hospital was, at the time, working towards full Baby Friendly accreditation, and had a breastfeeding initiation rate of 80%.
Purposive sampling was employed, with recruitment limited to midwives who worked mainly on the postnatal ward and in the community. Recruitment took place by individual invitation to any midwives meeting the inclusion criteria. While the potential for influencing the results due to self-selection was recognised, for the purposes of this study it was the most feasible way of recruiting.
Data collection
Five in-depth semi-structured interviews were conducted between September and October 2011, which were audio-recorded and transcribed verbatim. The interviews took place away from the clinical area to reduce any environmental effect (Rapley, 2004). To ensure trustworthiness of the data, respondent validation (Silverman, 2010) occurred at the time of the interviews, with frequent reference and paraphrasing by the interviewer to ensure understanding. Colaizzi's (1978) framework was used to analyse the data.
Ethical considerations
The study was granted ethical approval from a local ethics committee with a favourable opinion from the Trust's Research and Development Committee.
Findings
Themes
Three core themes emerged from the data, namely time poverty, the impact of being ‘with women’, and professional integrity (Table 1).
| Core theme | Sub-theme |
|---|---|
| Time poverty | Breastfeeding support and time hierarchy |
| Conditional vs unconditional motivation | |
| The impact on midwives of being ‘with women’ | Emotional impact on midwives |
| Giving permission to women to make the ‘wrong’ decision | |
| Empathising with women | |
| How midwives are seen by the women in their care | |
| Professional integrity | The questioning of professional credibility |
| Confidence in personal practice | |
| Accountability |
Theme 1: Time poverty
All midwives interviewed made frequent reference to time pressure, the impact this had on their practice and the judgements made when allocating their time to helping women. Within this overarching theme, there were two distinct sub-themes:
Breastfeeding support and time hierarchy
The amount of time the midwives anticipated spending on resolving breastfeeding problems, and the impact this had on the other areas of their work, was raised. Concern was expressed that they did not have the time needed to ensure women got the best possible care:
‘Providing the ward isn't too busy, I can give as much help as a woman needs, but if we have got all 24 beds full, then you have to obviously pull on your colleagues…’ (MWE3)
‘…it's mentally and physically hard work if you give your undivided attention… If all I've got to do is to help a mother it's fine. It's when you've got all the other things coming at you…’ (MWS1)
There was evidence that a lack of time meant that midwives felt they did not spend the time they felt was needed with breastfeeding mothers:
‘…yes, time is a massive issue. I think we could get babies feeding properly if we had more time, if you can literally sit there for a couple of hours with one mother, you can make a difference…’ (MWE1)
Because of the time needed when dealing with breastfeeding problems and the impact this can have on other areas, some midwives admitted to previously having felt relief when a woman had chosen to bottle-feed, as it meant they had time to spend elsewhere:
‘I'm very passionate about breastfeeding, but I can remember when I was a student… that if you had someone at handover that you heard was bottle-feeding there was almost a [sigh] that's one person that I know I won't have to spend a lot of time with discussing feeding, and I think there's still a little element of that today, but not so much…’ (MWS1)
Conditional vs unconditional motivation
Midwives recognised that their support made a real difference; they also acknowledged limited resources and the need for prioritisation.
‘Should time be spent with those who are really determined—they really value your support, but they're also determined, they're going to do it anyway—or do you spend time with those who are a bit unsure and if you do give them the time, then you might just encourage them to carry on?’ (MWS2)
Midwives eloquently described the judgements they make when allocating their time. While it was clear that midwives gave women help regardless of how they felt that those women would ultimately feed, they did occasionally wonder about women's motivation:
‘When it's really busy you have to make priorities, and when you do prioritise and a woman chooses to stop breastfeeding it's soul-destroying because you're like, I spent so long and I could have been doing this, this and that, but I didn't because she was so desperate to do it and I want her to have the experience, but then it's all gone out the window.’ (MWE1)
Theme 2. The impact on midwives of being ‘with women’
Midwives discussed the emotional impact on themselves when caring for women who were having problems with breastfeeding.
Emotional impact on midwives
The midwives in the study demonstrated an emotional connection to the women in their care, expressing strong feelings for those whose breastfeeding experience was less than positive. The language used by the midwives was often powerful, for example, ‘soul destroying’, ‘heartbreak’, ‘dread’, ‘distressing’ and ‘stressed’.
‘It's quite distressing, it's upsetting because you know it's not going to work. You know she can't get the baby on herself and you know she's going to go home.’ (MWS1).
‘There's nothing worse than seeing a new mum with her baby in tears. Your heart breaks for her.’ (MWE3)
One of the midwives used language that almost compared encountering breastfeeding problems to entering into battle:
‘You know when you go in it's going to be challenging and hard work… there is a sharing of feelings with other midwives, but it does become competitive… who can crack this one?’ (MWS1)
Midwives discussed how not being able to give care made them feel:
‘When you know you can't do your best because of all the other things to deal with, your heart sinks because you know you're going to have to walk away as opposed to thinking, “I really helped her to achieve…”’ (MWS1)
However, not all the feelings expressed were negative. When breastfeeding support was successful, midwives felt rewarded:
‘…when you help someone and they suddenly are able to do it [breastfeed] by themselves, you feel good that you've helped someone achieve what they wanted to do and it's quite rewarding.’ (MWE1)
Giving permission to women to make the ‘wrong’ decision
Some of the midwives identified that women occasionally choose to breastfeed because they felt it was ‘expected’. They spoke of their role in regard to women's decision-making:
‘I never, ever do the guilt trip; if a woman makes the choice to stop, then it is her choice and her decision… however pro-breastfeeding I am. I suppose I'm more pro Mum staying sane and being happy with what she's doing.’ (MWE2)
This theme was echoed by another midwife, who spoke of the perceived social pressures on women to feed in a particular way:
‘I usually find in practice women that are obviously just having a go because they are living where they are living and behaving as expected.’ (MWS1)
Later, this midwife described how she would give a woman whom she felt was not happy breastfeeding ‘permission’ to bottle-feed:
‘Quite often at that point, I say, “Well, to be perfectly honest, if you're not happy and you're getting upset and stressed out and you're hating every minute of this, emotionally that's not very good [for] either of you… It will be much better for both of you, physiologically, if you bottle-feed, if that's what you want to do.”’ (MWS1)
Empathising with women
Midwives empathised with women when they encountered breastfeeding problems:
‘When you take the report you think oh, this poor woman, she's struggling, I feel really awful for her, I'm going to make sure I go and help her.’ (MWE3)
Empathy also came from a midwife's own experience of breastfeeding:
‘Probably a certain degree of sadness came from my personal experience of breastfeeding; I've had three children but certainly the first was hugely difficult.’ (MWS1)
How midwives are seen by the women in their care
The belief that some women made feeding decisions in line with what they thought their midwives would want led to distress among participants:
‘There was one particular lady… she decided to give up breastfeeding, so I went, “that's fine” and she burst into tears and I said, “oh, wasn't that what you wanted me to say?” She's said, “I thought you were going to tell me off, I thought you were going to be angry because I was stopping breastfeeding.”’ (MWE2)
When asked about how this made her feel, the midwife responded:
‘I was saddened by that… because she thought we would be cross, the fact that, you know, she thought, a midwife, whoever it would be, would tell her off for stopping breastfeeding.’ (MWE2)
The subject of how midwives were seen by the women in their care led to strong, emotional language:
‘I usually quite openly ask them, “If you don't think we have an opinion at all, how would you want to feed your baby?” And they quite often look at you like it's a trick question, and they're about to be shot by the breastfeeding Gestapo…’ (MWE1)
When asked how this made her feel, the midwife responded:
‘That they're scared of us? It's horrible. Really awful. It makes you sit there thinking… “We're getting the message wrong.”’ (MWE1)
Theme 3. Professional integrity
Within the theme of maintaining professional integrity, participants expressed how they felt their personal professional integrity and credibility were called into question.
‘If you can identify the problem, then you're two thirds of the way to sorting it. It's whether you've got the time to do it. Time is the biggest constraint’
The questioning of personal professional credibility
Some of the midwives felt their personal professional credibility had been questioned and sometimes undermined, often in relation to the need to demonstrate that they were providing a standard of care expected to achieve accredited Baby Friendly status.
‘The standard answer is skin-to-skin, latching the baby. Well, it's a bit insulting to be told you don't know how to latch a baby, when you've been doing it for 5 years.’ (MWE1)
The language this midwife used is interesting, as it seems to imply that latching a baby onto the mother's breast was something the midwife actively did, rather than helping the mother to achieve this herself.
Confidence in personal practice
Overall, the midwives in this study were confident that they could solve most of the breastfeeding problems they would encounter, if there was enough time available:
‘If you can identify the problem, then you're two thirds of the way to sorting it. It's whether you've got the time to do it. Time is the biggest constraint…’ (MWE2)
‘If I don't have any other pressures on the work, then yes, I would be confident. I just can't always guarantee the time.’ (MWS2)
Accountability
Professional accountability was mentioned by a number of midwives. Their overarching concern was the health of the baby and mother, and this concern underpinned their practice.
‘There's only so long you can leave a baby that is not feeding… I think nobody wants to be responsible for having missed something [in relation to potentially missing an ill baby]… I wouldn't feel happy leaving work, knowing there [was] something I should have checked.’ (MWE1)
‘…and I think even if you're very busy, you have accountability to ensure that the baby is receiving nourishment and is safe, but that doesn't mean you've achieved the best standard of care you could.’ (MWS1).
Discussion
The midwives in this study all described working under considerable time constraints, which had a negative impact on the level of support they were able to give to the women in their care. This sense of ‘time poverty’ led to a feeling of dissatisfaction, which in turn led to what could be termed conditional/unconditional motivation. Despite the fact that they all spoke of giving breastfeeding women time, the midwives questioned whether this time would be ‘rewarded’ with a successfully breastfeeding mother. The perception expressed by the midwives of having to work as efficiently as possible, without being able to give a woman their full attention, echoed previous findings (Dykes, 2009) and has been highlighted by the RCM (2014).
Regardless of the impact of time poverty, midwives demonstrated an emotional connection with the women in their care. Powerful language indicated their empathy; the emotional impact was greatest when they felt they were not able to provide the highest standard of care. The role of advocacy, which is central to being a midwife (Nursing and Midwifery Council (NMC), 2015), was illustrated when midwives described support given to women who chose to bottle-feed. The midwives expressed a perception that these women felt they were doing something ‘wrong’; midwives had to counter the idea that women might be ‘told off’ for making a decision that they felt was right for them.
Conclusions
This study has shown that breastfeeding support has an emotional impact on midwives, particularly when they encounter women who are having difficulties; this supports other findings in this underexplored area (Furber and Thomson, 2006; 2008a; 2008b; Battersby, 2009). The midwives who participated in this study displayed an emotional connection with the women they were caring for; it mattered to them that these women were able to feed in a way that was right for them.
The study focused on workplace stress, with staff shortages (Warwick, 2004) leading to stress and frustration. With reports of an increasing shortage of midwives (RCM, 2011), the feeling of time poverty is likely to increase, leading to greater dissatisfaction among midwives. Workable solutions must be sought to support both breastfeeding women and midwives.
Key Points
Conflict of interest: The authors have declared no conflict of interest.