Health Professionals’ Attitudes and Beliefs About Breastfeeding

ABSTRACT

The aim of this descriptive study was to investigate how health-care providers perceived their role in breastfeeding and maternal support. Data was collected via interviews of 53 health-care professionals that provided care to breastfeeding women. The emerging themes included (a) understanding the benefits of breastfeeding: often lacking current knowledge, (b) lacking consistency: gaps between knowledge of benefits and actual clinical practice, (c) not knowing how to help: lack of assessment and therapeutic skills, and (d) understanding the barriers to breastfeeding: how health-care providers can make a difference. Data analysis suggests inconsistencies between the health-care provider’s perceived support and behaviors, lack of knowledge, and significant lack of skill in the assessment and management of breastfeeding couples.

The importance of breastfeeding in enhancing infant and maternal health has been well documented in the professional literature (U.S. Department of Health and Human Services [USDHHS], 2011). Public health data indicate that if 90% of infants were breastfed exclusively for 6 months, the United States would save $13 billion annually through reduced health-care costs. Beyond cost savings, data supporting the unparalleled immunologic and anti-inflammatory properties of breastmilk in maternal/child health promotion and disease prevention are highly significant (Benjamin, 2011; Kim & Froh, 2011).

Public health data indicate that if 90% of infants were breastfed exclusively for 6 months, the United States would save $13 billion annually through reduced health-care costs.

Despite these impressive data, breastfeeding rates remain below recommended standards endorsed by the American Academy of Pediatrics (AAP; Gartner et al., 2012), World Health Organization (WHO), and the USDHHS (2011). According to the Centers for Disease Control and Prevention’s (2010) Breastfeeding Report Card, 75% of new mothers begin breastfeeding, but by 6 months, breastfeeding rates are 42% and only 13% of infants are exclusively breastfed. The Healthy People 2020 objectives for breastfeeding are 82% ever breastfed, 61% at 6 months, and 34% at 1 year (USDHHS, 2010).

Multiple variables have an impact on the decision to breastfeed, initiation of breastfeeding, and maintaining breastfeeding for at least 6 months, including personal and professional support. A Cochrane systematic review concluded that experiencing support extends the duration of breastfeeding significantly (Britton, McCormick, Renfrew, Wade, & King, 2007). A more recent study found that factors related to initiation and duration of breastfeeding between hospital discharge and 2 weeks postpartum were positively influenced by having a perceived support system (Brand, Kothari, & Stark, 2011). The Office of the Surgeon General has identified the need for health-care systems to “guarantee continuity of skilled support for lactation between hospitals and health care settings in the community,” including education for all health professionals who care for women and infants (USDHHS, 2011, p. 49). Limited research could be found on the perceived attitudes and beliefs of health-care providers, including physicians in training in relation to breastfeeding support. Therefore, the research question for this study is, what are the perceptions of health-care providers regarding breastfeeding and support of breastfeeding?

The Healthy People 2020 objectives for breastfeeding are 82% ever breastfed, 61% breastfed at 6 months, and 34% breastfed at 1 year.

LITERATURE REVIEW

Determinants of the maternal decision to breastfeed include maternal knowledge and attitudes as well as professional and personal support. Women in higher socioeconomic groups with higher levels of maternal education are more likely to choose breastfeeding. Additional factors include sociocultural context; attitudes of family and friends, especially the infant’s father; and the support and involvement of health-care professionals (Bai, Middlestadt, Peng, & Fly, 2009; McInnes & Chambers, 2008).

There is a body of literature related to health-care professionals and breastfeeding. Physicians have been identified as having a significant influence on breastfeeding initiation rates and duration. As early as 1992, Freed, Jones, and Fraley found that pediatric interns were more likely to encourage breastfeeding and recognize early formula implementation than third-year residents. Over a decade later, Taveras et al. (2004) reported that women who discontinued breastfeeding within the early postpartum weeks reported their health-care provider recommended formula supplementation. Mothers expected their health-care providers would have the knowledge and skills to assist them with common breastfeeding concerns. Other researchers found that women reported advice and encouragement by their health-care providers was superficial and insufficient (Dillaway & Douma, 2004). Szucs, Miracle, and Rosenman (2009) conducted focus groups with various health professionals, finding that there were gaps in providers’ knowledge and communication skills and their support of breastfeeding. They identified the need for “continuous, comprehensive, coordinated, culturally effective evidence-based breastfeeding promotion and support” (p. 31).

A significant lack of breastfeeding knowledge among health-care providers means that women may receive inappropriate and often conflicting information resulting in premature weaning (Bäckström, Wahn, & Ekström, 2010; Nelson, 2007; Verd, de Sotto, González, Villalonga, & Moll, 2007). Lack of skill and inadequate time needed to manage breastfeeding problems also affect the level of health providers’ involvement. According to the AAP (Gartner et al., 2012) policy statement on breastfeeding, pediatricians showing an interest in plans for infant feeding had a positive impact on the decision to breastfeeding. Pediatricians who were ambivalent had a negative impact.

Nurses are very influential regarding breastfeeding success rates both in the initiation of breastfeeding and duration. Nurses’ knowledge regarding breastfeeding and their attitudes about breastfeeding are predictive of actual supportive behavior. However, nurses’ knowledge continues to be deficient specifically in areas such as lactation physiology and glucose feedings. In a study of the knowledge and attitudes of nursing staff in 27 private pediatric practices, many nurses had both inadequate knowledge and negative attitudes about breastfeeding. Although most (83%) office nurses felt breastfeeding promotion was good use of their time and follow-up with a new breastfeeding mother was within their role description, only 46% felt confident with working with a mother with breastfeeding problems (Register, Eren, Lowdermilk, Hammond, & Tully, 2000). In a study of pediatric nurses, there was moderate breastfeeding knowledge and attitudes, and those with personal breastfeeding experiences had significantly higher knowledge and attitude scores (Brewer, 2012).

Maternal perceptions of negative attitudes of hospital staff have been found to be predictive of breastfeeding failure at 6 weeks postpartum. Mothers reporting perceived neutrality on the part of the hospital staff in relation to their decision to breastfeed were significantly more likely to wean by 6 weeks (DiGirolamo, Grummer-Strawn, & Fein, 2003).

Multiple studies indicate that nurses as well as physicians refer breastfeeding mothers to lactation consultants when problems arise. Data are difficult to interpret, however, because there is no consistency in the literature regarding the qualifications and training of individuals professing to be lactation consultants. The International Board Certified Lactation Consultants (IBCLCs) documented a positive association between giving birth at a hospital that employs IBCLCs and breastfeeding at hospital discharge (Castrucci, Hoover, Lim, & Maus, 2006). The need was identified for further research on the perceptions of health-care providers regarding the importance of breastfeeding and their provision of breastfeeding support.

METHOD

In this qualitative descriptive study, following institutional review board approval and informed consent, data were collected through hour-long interviews of the participants in a quiet anteroom adjacent to the birthing suite or the mother/baby unit. Convenience sampling was employed. The interview consisted of five questions that began with a broad question, “Tell me what your opinion is about breastfeeding.” This allowed the study participants to identify any aspect of breastfeeding that was important to them. Because all participants had positive responses to the initial question, the follow-up questions were designed to see the participants’ perceived role and whether their actions, behaviors, and professional practice were consistent with their overall support of breastfeeding. Question 2, “What do you think is important for the patient to know about breastfeeding?” was designed to look at the participants’ knowledge of the subject and their perceived role in patient education. Question 3, “Do you ever encourage your patients to breastfeed if they are undecided or think they would rather formula feed?” was designed to look at how the participants see their role in infant-feeding decision making as well as actions or behaviors that may or may not be consistent with their opinion of breastfeeding. Question 4, “How do you assess your breastfeeding patients?” was designed to further look at role perception and professional practice. Question 5, “Why do you think so many women stop breastfeeding within a few weeks or months after giving birth?” was designed to look at continued professional support provided to the mother–infant dyad on a long-term basis. Study participants also completed a demographic form (see Table 1). Interviews were audio recorded and transcribed verbatim. Following transcription of the interviews, data were analyzed by the principal investigator. Categories emerging from the data were identified and named. Study participants were recruited until saturation was achieved in each category and all characteristics of the category were present and identified. Categories were reexamined, and those with similar characteristics were clustered together into a reduced number of categories. Each category was examined for instances that contradicted the characteristics defined by the category and reclassified (Graneheim & Lundman, 2004).

TABLE 1. Demographic Data.

Professional Role	Gender	Age Range (Years)	Years of Practice	Personal/Spouse Breastfeeding Experience	Birth Country
Obstetricians	6 males	42–56	11–26	4 = yes, 2 = no	United States
	1 female	44	13	1 = yes	United States
Pediatricians	5 males	39–59	9–29	3 = yes	United States
				2 = no
Obstetric residents	4 females	26–30	1–4	4 = no	United States
Pediatric residents	2 males	27–31	1–4	2 = no	United States
					United States
	4 females	26–30	1–4	4 = no
Nurse-midwives	5 females	34–46	2–14	3 = yes	United States
				2 = no
Nurses	22 females	20–54	1–33	12 = yes	United States =14
					Other = 8
					Guyana = 2
					Nigeria = 2
					Zimbabwe = 1
					Ghana = 1
					Germany = 1
				10 = no	Albania = 1
Lactation consultants	4 females	29–45	1–5	4 = yes	United States

The sample consisted of 53 health-care professionals providing care to breastfeeding women and their infants. This included pediatricians, obstetricians, nurse-midwives, obstetric and pediatric residents, nurses, and certified lactation consultants. Data were obtained from 5 male pediatricians in private practice (3 of whom had wives who combined breast/formula feeding and 2 who formula fed), 6 male obstetricians (3 with wives who combined breast/formula feeding, 1 who breastfed, 1 who formula fed, and 1 who did not have children) and 1 female obstetrician (who combined breast/formula feeding), 5 female certified nurse-midwives (3 breastfed and 2 did not have children), 4 female and 2 male pediatric residents (none had children), 4 female obstetric residents (none had children), 22 female nurses (4 breastfed, 8 combined breast/formula feeding, and 10 did not have children), and 4 female certified lactation consultants (2 breastfed and 2 combined breast/formula feeding). The age of the participants ranged from 20 to 59 years with the mean age of 36 years. All of the participants were from the District of Columbia and practiced at a large tertiary medical center.

RESULTS

Themes included (a) understanding the benefits of breastfeeding: often lacking current knowledge; (b) lacking consistency: gaps between knowledge of benefits and actual clinical practice; (c) not knowing how to help: lack of assessment and therapeutic skills, particularly when there were challenges in breastfeeding and referral was needed; and (d) understanding the barriers to breastfeeding: how health-care providers can make a difference.

Understanding the Benefits of Breastfeeding: Often Lacking Current Knowledge

All respondents described the benefits of breastfeeding, and one said breastfeeding is the “best thing a health professional can encourage.” Physicians were more likely to identify the immunologic benefits for infants, whereas nurses concentrated on maternal–infant bonding, nutritional benefits for the infant, maternal weight loss, and cost-effectiveness. One pediatrician felt it was essential that mothers understand the role immunoglobulins played in the prevention of allergies. Another pediatrician emphasized the importance of breastmilk for premature infant’s immune function and development. Residents reported that they knew about the reduction of infection as a benefit but had little knowledge about the subject.

Nurses felt that practical knowledge such as how to position an infant at breast and how to assist the baby to latch on was extremely important. All felt early initiation of breastfeeding immediately after birth should be emphasized. There was a distinct difference in opinion among nurses about how breastfeeding was presented. Many nurses stated that mothers should be told how easy breastfeeding was. Others felt it was important for mothers to know that breastfeeding was not as easy as it looked. One nurse commented that “mothers should be told up front that it is a lot more difficult to do than it looks like [in the media]. You don’t just automatically hold a baby to the breast and they get it . . . ”

Nurses and certified lactation consultants commented that mothers should have realistic information on what to expect when breastfeeding an infant. One lactation consultant commented that

the most important thing a mother needs to know is that they don’t have milk the first couple of days just colostrum . . . Mothers seem to think they are going to [give birth to] this baby and milk is just going to come flowing out. They need to know what to realistically expect; otherwise, they end up disappointed or think they don’t have enough milk. It doesn’t help either that the only thing the pediatrician tells them each morning is how much weight their baby has lost. They need to know that they will produce the amount of milk their baby will need.

Lacking Consistency: Gaps Between Knowledge of Breastfeeding Benefits and Actual Clinical Practice

Because the benefits of breastfeeding were identified by all health-care professionals, there was a gap between knowledge and actually recommending and encouraging breastfeeding in clinical practice. Respondents felt that they were very supportive of women who had already made the decision to breastfeed. For those who were undecided, most stated that they recommended breastfeeding and provided the mother with pamphlets or written materials describing the benefits of breastfeeding but did not “push it.”

One birthing nurse stated that she routinely put the baby to the mother’s breast immediately after birth if the mother was undecided about her decision regarding infant feeding. She encourages the mother to “just try it.” She stated that once new mothers get their newborn latched on, the mothers love it. For women who decided to formula feed, none of the health-care providers in the study indicated that they would ask a mother to reconsider her decision. One nurse commented that she “never asks a patient to breastfeed once they indicate they want to bottle feed” but was not sure why she didn’t. Most nurses and physicians stated that the reason that they do not address breastfeeding with mothers who indicate they want to formula feed is that they do not want the mothers to feel guilty about their decision. One pediatrician stated that he “didn’t want the mother to feel formula feeding was bad for the baby or that she was being judged by me.” One nurse stated, “If they want to bottle feed, I do not force the issue because I don’t want them to feel shame.”

Three of the four certified nurse-midwives in the study stated they routinely provided information to women prenatally when they inquired about infant feeding. One midwife stated, “I always suggest to my patients that they should consider breastfeeding. I tell them about the benefits and always include a pamphlet in their prenatal packet.” Another midwife commented, “Breastfeeding literature is always part of the information I give patients on their first prenatal visit. If she decides to bottle feed, however, I don’t want her to feel bad about her decision so I don’t push the issue.”

An obstetrician noted,

I have infant feeding literature in the waiting room of the office, and patients are encouraged to help themselves. In the end, however, the mother has to make a decision that is right for her and her baby. I do not think it is the role of the physician to make that decision for her.

Another obstetrician said,

Our prenatal materials always contain information about breastfeeding, including a list of names of books they can purchase on the subject. If a patient asks me questions, I always emphasize that “breast is best” and try to answer her questions as best I can. I don’t have a lot of time to spend with patients on these types of issues, so I refer them to their pediatrician or to the list of lactation consultants and the La Leche League leaders we have in this area.

The pediatric residents in the study indicated that they never considered discussing infant feeding with mothers, “I leave it up to the mothers to make the decision. It’s their choice after all. I don’t think I should have anything to do with it.”

Not Knowing How to Help: Lack of Assessment and Therapeutic Skills

Regarding their role in assessing the mother–infant dyad in relation to breastfeeding or diagnosing breastfeeding problems, physicians unanimously indicated that breastfeeding assessment was confined to asking the patient about it and evaluating infant weights. Nurse-midwives, mother/baby nurses, and lactation consultants said that observing the breastfeeding couplet and questioning the mother were the most common assessment methods they used. They identified observing the feeding for positioning and latch-on as being most significant. Daily assessment of the mother’s nipples was also commonly mentioned. One nurse stated she would observe the breastfeeding session only if the mother stated she had concerns. Another nurse stated she had done no routine assessments because the “mom will get it eventually by trial and error.” Birthing nurses stated that they do little breastfeeding assessment because “if the baby has trouble latching on or is too sleepy after birth, I do not see it as a problem. The baby will just learn to do it later.”

Residents in the study indicated that they do not assess breastfeeding. If the mother indicates she is having problems, they refer her to the nurses or lactation consultants. One pediatric resident commented, “I have never seen a woman breastfeed, and frankly, I don’t want to. I would not even know what to look for. The nurses here are experts in this area, and they handle any problems the mother might have.”

Understanding the Barriers to Breastfeeding: How Health-Care Providers Can Make a Difference

Maternal employment was identified as the most dominant barrier to breastfeeding. One pediatrician said,

Most women today have to work. They don’t have the luxury of staying home with their baby, and you just can’t expect a baby to sit around all day waiting for his mother to come home so he can eat. I tell my patients that in the end, what is most important is that the baby is well cared for and healthy. The method used to feed a baby isn’t the most important thing.

Several nurses said in the discharge teaching they discussed returning to work and introduced the idea of pumping routinely.

One obstetrician said,

Many women have enough of a hard time going back to work without the added stress of breastfeeding; most work places do not support their employees and they feel ostracized. A lot of my patients feel embarrassed to pump in public bathrooms and have trouble with milk leaking on their clothes. They often have to endure off color comments from their coworkers. Unless they really feel strongly about continuing to breastfeed, I support them by helping them wean when they go back to work. If they really want to combine breastfeeding with work, I think that’s wonderful and provide them with very positive feedback. I give them information about breast pumps and how to keep up their milk supply. I also usually refer these mothers to a lactation consultant.

Unrealistic expectations, lack of time, and inconvenience were also barriers identified. Several lactation consultants identified barriers such as maternal or infant frustration with the process and lack of support from family and friends, citing that mothers lose interest once they get home and are faced with the realities of daily life. Once mothers assume other household responsibilities, they may become less devoted to breastfeeding. One pediatrician noted mothers report they simply do not have the time it takes, with formula feeding viewed as more time efficient and easier to manage.

Some respondents did not feel health-care professionals had an effect on a mother’s decision to discontinue breastfeeding. One nurse-midwife commented, “I do what I can to encourage them, but in the end, they go home to husband and family. If they do not have support in the home, there is nothing anyone can do.” Residents said they would support any decision mothers made about discontinuing breastfeeding. They all felt the method of infant feeding was the mother’s decisions, and they should be free to do whatever they preferred. Most of the nurses indicated that they had little or no contact with the mother after hospital discharge and it was out of their control.

The Surgeon General’s call for action notes that “there are few opportunities for future physicians and nurses to obtain education and training on breastfeeding, and the information on breastfeeding in medical texts is often incomplete, inconsistent, and inaccurate.”

Other pediatricians and obstetricians commented that if a mother was having trouble and indicated she wanted to stop, they may refer her to a lactation consultant or give her literature depending on whether the mother was having trouble breastfeeding or wanted to stop because of time or employment restrictions.

IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH

Limitations of the study include the fact that this is a cross-sectional study and interviews were conducted with study participants only once. Also, findings reflect the perspectives of a convenience sample which may limit the transferability of the findings of this study.

Changing health-care providers’ attitudes and beliefs is essential to increase support and promotion of breastfeeding. In an outcomes study of the effect of a practice development initiative to improve breastfeeding roles among health-care providers, Barnes, Cox, Doyle, and Reed (2010) reported that education of health-care providers was associated with increased rates of breastfeeding, higher levels of maternal satisfaction, and a higher level of professional knowledge and skills.

A systematic review of intervention studies focusing on increasing the breastfeeding knowledge, self-confidence, and supportive behaviors of health-care professionals reported that breastfeeding education is effective in increasing the knowledge and confidence of nurses. Conflicting results were found on the effectiveness of breastfeeding education in other professionals, with no increase reported by mothers in satisfaction with their breastfeeding support after health-care providers received additional education (Watkins & Dodgson, 2010). More research is recommended to identify what kind of professional support is most helpful to new mothers.

Implications for clinicians are summarized in Table 2. The Surgeon General’s call for action notes that “there are few opportunities for future physicians and nurses to obtain education and training on breastfeeding, and the information on breastfeeding in medical texts is often incomplete, inconsistent, and inaccurate” (USDHHS, 2011, p. 46). However, there are educational resources available, including a resource toolkit for hospitals and physicians’ offices on breastfeeding (AAP, 2008). The World Health Organization and United Nations Children’s Fund (2009) has developed a model chapter for textbooks for medical students and allied health professionals on infant feeding, which may prove helpful to implement in medical and nursing education curriculum.

TABLE 2. Clinical Implications.

Improve the education of health-care professionals on breastfeeding using evidence-based, clinically focused learning approaches. Assess maternal knowledge of infant feeding options and encourage breastfeeding. Provide maternal education on the benefits of breastfeeding, including available community resources across care settings. Assess maternal knowledge of the impact of birthing pain management on infant responses and successful breastfeeding. Assess maternal knowledge of nonpharmacologic birthing pain management. Encourage ambulation, position changes, oral hydration, and nourishment during labor. Provide skin-to-skin contact immediately after birth. Delay interventions such as eye prophylaxis, vitamin K injection, and first bath until after initial breastfeeding. Initiate maternal pumping within the first hour following birth if the infant is immediately transferred to the NICU. Make referrals to certified lactation consultants as appropriate. Support and encourage breastfeeding mothers across the childbearing year.

Note. NICU = neonatal intensive care unit.

The Surgeon General’s call for action notes that “there are few opportunities for future physicians and nurses to obtain education and training on breastfeeding, and the information on breastfeeding in medical texts is often incomplete, inconsistent, and inaccurate.”

The World Health Organization Baby-Friendly Hospital Initiative and Ten Steps to Effective Breastfeeding are other excellent resources associated with a significant increase in exclusive breastfeeding (Britton et al., 2007). These resources include online staff training for physicians and nurses (Labbock, 2012). Continuing education offerings across specialties, including physicians in training, should appropriately focus on breastfeeding using evidence-based, clinically focused learning approaches (Dodgson & Terrant, 2007). Gaining knowledge about breastfeeding contributes to changing the attitudes and beliefs of health-care providers about breastfeeding.

Gibson, Bowles, Jansen, and Leach (2012) have identified what they term another ten steps for intrapartum nurses to promote breastfeeding beginning with the woman’s admission to the birthing unit. Further research is suggested on the effects of these interventions on the initiation and continuation of breastfeeding.

Even prior to the woman giving birth, promoting breastfeeding should be the focus of perinatal educators who should be knowledgeable both about the benefits of breastfeeding and available community resources (Philipp, 2010). In addition, a lactation specialist may be invited to be a guest speaker or perinatal educators may seek IBCLC certification. Women may be referred prenatally to certified lactation consultants as appropriate, in addition to postpartum consultation. Having certified lactation specialists as part of the health-care team is a highly recommended strategy (Thurman & Allen, 2008). Online resources, as well as media and print resources, should be made available to expectant mothers making important decisions about infant feeding.

It is essential that professionals gain knowledge about available community resources, so mothers can be referred to receive needed help. This may include referral to a certified lactation consultant, the La Leche League, and outpatient breastfeeding services associated with hospitals and health-care systems. Addressing the call for action by the Surgeon General to ensure perinatal care practices are fully supportive of breastfeeding includes guaranteeing the continuity of skilled support for breastfeeding mothers between acute care and community health-care settings (USDHHS, 2011).

Pérez-Escamilla and Chapman (2013) speak of this as being “a time to nudge” (p. 118) health-care providers in the promotion and support of breastfeeding. This study extends the findings of current literature regarding professional support of breastfeeding. The attitudes and beliefs of health-care providers need to be changed through education to increase the effectiveness and efficacy of professional support of breastfeeding.

Biographies

SHARON RADZYMINSKI is a maternal–infant clinical nurse specialist and has over 20 years’ experience with breastfeeding infants and mothers. She has conducted research on breastfeeding and infant feeding for almost two decades.

LYNN CLARK CALLISTER has conducted cross-cultural studies of childbearing women in multiple socio-cultural contexts for nearly three decades. She is a member of the March of Dimes Nurses Advisory Council and Bioethics Council and the American Academy of Nursing Global Health Expert Panel. She is highly committed to improving the health of women and newborns throughout the world.