‘Breaking the rules’ in baby-feeding practice in the UK: deviance and good practice?
Introduction
Baby feeding (especially breast feeding) is one of the most critically debated areas of maternal and neonatal health care. Research has shown that breast feeding is undisputedly the superior means of providing nutrition for the newborn baby, with health benefits to the baby (Howie et al., 1990; Wilson et al., 1998; Paronen et al., 2000; Mortenson et al., 2002; Burke et al., 2005), as well as the mother (Cumming and Klineberg, 1993; Rosenblatt and Thomas, 1993; Collaborative Group on Hormonal Factors in Breast Cancer, 2002).
However, in the UK, babies are generally either exclusively breast fed, exclusively artificially fed, or ‘mixed-fed’ with breast milk and artificial milk or cows’ milk (Hamlyn et al., 2002). The UK government's 5-yearly survey of infant feeding practices shows that mothers who start breast feeding at birth may not exclusively breast feed for the recommended duration (Hamlyn et al., 2002). In fact, mothers in the UK fall far short of the World Health Organization's (WHO) recommendations that all babies should be exclusively breast fed for the first 6 months of life (WHO, 2002). Hamlyn et al. (2002) found that 69% of mothers started breast feeding at birth; however, only 21% were still feeding their baby this way at 6 months of age.
The attitudes to, and opinions of, mothers towards baby feeding have been extensively researched worldwide; baby feeding is a major anxiety for new mothers (e.g. Smith, 1989; Singh and Newburn, 2000). However, most studies relate to breast feeding, rather than artificial feeding. Scott and Binns (1998) reviewed the literature and concluded that multiple factors are related to the initiation and duration of breast feeding in Western women. These factors reflect social, psychological, cultural and economic issues, as mothers in Western societies who are most likely to breast feed include older women, women from higher socio-economic groups, and women who have significant support (Hamlyn et al., 2002; Callen and Pinelli, 2004). Research has shown that breast feeding is part of the mother's ‘way of life’, such as being breast fed herself, having peers who breast feed and having the opportunity to observe mothers breast feeding (Hoddinott and Pill, 1999; Meyerink and Marquis, 2002). However, breast feeding is not always straightforward. For some, research has shown that this is a period of intense pride (MacLean, 1990) and facilitation of closeness between mother and baby (Grossman et al., 1990; Schmied and Barclay, 1999). For others: breast feeding is painful (Green et al., 1998; Higginbottom, 1997), exceedingly tiring (Carter, 1995), and requires stoicism to persevere (Bottorff, 1990; Schmied and Barclay, 1999). Furthermore, the new mother's need for support during the feeding process has been highlighted by several studies from the UK, Australia, Sweden and the USA. For example, practical support related to breast and artificial feeding is significant (Hughes and Rees, 1997; Scott and Mostyn, 2003; Lin et al., 2004; Chamberlain et al., 2005; Graffy and Taylor, 2005); and for breast feeding, social and emotional support are important (Higginbottom, 1997; Dykes et al., 2003; Ekstrom et al., 2003; Scott and Mostyn, 2003).
Most babies in the UK are born in hospital (Office for National Statistics, 2004), and therefore start their life in the care of hospital personnel (midwives, support staff and paediatricians), as well as their mother. Moreover, baby-feeding support in British hospitals has often been criticised by new mothers, with the provision of ‘contradictory and condescending information from midwives’ (Green et al., 1998, p. 370), and inadequate support (Singh and Newburn, 2000; Dykes, 2005). This is despite concerted efforts to promote breast feeding in the UK through, for example, the provision of research-based guidelines for breast-feeding practice for midwives since 1988 (Royal College of Midwives [RCM, 2002], government policy supporting breast-feeding choices (Department of Health, 1993, Department of Health, 2004) and the introduction of the United Nation's Children Fund (UNICEF) and WHO's Baby Friendly Initiative (BFI) to the UK in 1994 (Warren, 1999). During this period of breast-feeding promotion, the opinions and practices of the health professionals involved in the provision of baby-feeding support in UK hospitals have not been widely researched. Nonetheless, the studies that have explored midwives’ baby-feeding practices in the UK suggest that the practices used by midwives were not always research-based, and that they often did not follow guidelines for practice (Garforth and Garcia, 1989; Beeken and Waterston, 1992; Cairney and Alder, 2001; Cloherty et al., 2004).
Section snippets
Methods
The aim of this study was to discover the views of midwives in relation to baby feeding. A qualitative approach, using the grounded theory method (Glaser and Strauss, 1967), was used. Grounded theory was selected because of its ability to respect the views of those being studied and to enable their problems and concerns to emerge from the collected data (Glaser, 1992).
Characteristics of the midwives interviewed
The midwives who participated were all women: 20 were mothers and 10 were childless. Their clinical experience as midwives varied, with the shortest duration being 8 months and the longest 31 years. Twenty-two of the participants worked solely in the hospital clinical environments, whereas six were community midwives. A further two midwives worked as ‘team’ midwives providing integrated care across both the hospital and community settings (Allen et al., 1997). These midwives’ educational
Discussion and implications for practice
Only one method of data collection was used (interviews) in this study, and these midwives were not ‘observed’ in their practice. Normally, it cannot be assumed that what they said they did in their practice is what actually happened. However, during a presentation of the findings to the participants of this study, the midwives were asked if they would allow a researcher to observe routines such as those disclosed by these midwives. The response was emphatically ‘no’, but the midwives present
Conclusion
These midwives have honestly explained some of the strategies that they used in supporting mothers with baby feeding, particularly in the hospital. Despite some practices being commendable, others have highlighted behaviour that does not adhere to evidence-based guidelines, and risks being negligent (or labelled as deviant) in relation to UK professional standards (NMC, 2004). However, this study reiterates that the midwifery cultural background is not always conducive to individuals providing
Acknowledgements
This study was funded entirely by the School of Nursing, Midwifery and Social Work of The University of Manchester, UK.
References (92)
- et al.
Breastfeeding and overweight. Longitudinal analysis in an Australian birth cohort
The Journal of Pediatrics
(2005) - et al.
Supplementing breast-fed babies in the UK to protect their mothers from tiredness or distress
Midwifery
(2004) ‘Taking time and touching base’ A critical ethnographic study of encounters between midwives and breast-feeding women in postnatal wards in England
Midwifery
(2005)- et al.
Breastfeeding policies in practice: no wonder they get confused
Midwifery
(1989) An Australian study of functional status after childbirth
Midwifery
(1997)- et al.
Positioning intervention to minimize fatigue in breastfeeding women
Applied Nursing Research
(1996) Searching for autonomy
Midwifery
(2003)Postnatal concerns of mothers: an update
Midwifery
(1989)Litigation and defensive clinical practice: quantifying the problem
Midwifery
(2000)- et al.
A Leading Role for Midwives?
(1997)
Outsiders Studies in the Sociology of Deviance
Health service support of breastfeeding – are we practising what we preach?
British Medical Journal
Postnatal Care Evidence and Guidelines for Management
Supplementary feeding in the maternity ward shortens the duration of breast feeding
Acta Paediatrica
Techniques in validation in qualitative research: a critical commentary
Persistence in breastfeeding: a phenomenological investigation
Journal of Advanced Nursing
A survey of information given by health professionals, about bottle feeding, to first-time mothers in a Scottish population
Health Bulletin
Incidence and duration of breastfeeding for term infants in Canada, United States, Europe, and Australia: a literature review
Birth
Feminism, Breasts and Breast-Feeding
Calls to an inner-city hospital breastfeeding telephone support line
Journal of Human Lactation
Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries including 50302 women with breast cancer and 96973 women without the disease
Lancet
Informed consent is a primary requisite of quality care
British Journal of Midwifery
Single daily bottle use in the early weeks postpartum and breastfeeding outcomes
Pediatrics
Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women
International Journal of Epidemiology
Adolescent mothers and breastfeeding: experiences and support needs – an exploratory study
Journal of Human Lactation
Breastfeeding support from partners and grandmothers: perceptions of Swedish women
Birth
Surviving complaints and statement writing
RCM Midwives Journal
Breastfeeding: the great divide the controversy as seen through a midwifery lens
MIDIRS Midwifery Digest
Nature, severity and correlates of psychological distress in women admitted to a private mother-baby unit
Journal of Paediatric Child Health
Sleep patterns and fatigue in new mothers and fathers
Biological Research for Nursing
Theoretical Sensitivity
Basics of Grounded Theory Analysis Emergence vs. Forcing
Doing Grounded Theory: Issues and Discussions
The Grounded Theory Perspective: Conceptualization Contrasted with Description
The Discovery of Grounded Theory: Strategies for Qualitative Research
Supplementation in the hospital setting
Journal of Human Lactation
What information, advice, and support do women want with breastfeeding?
Birth
Great Expectations A Prospective Study of Women's Expectations and Experiences of Childbirth
Infant feeding decision in low and upper income women
Clinical Paediatrics
Postnatal emotional wellbeing
The Practising Midwife
Breastfeeding: A Guide for Midwives
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