21

BIRTH 39:1 March 2012

Learning the Hard Way: Expectations and

Experiences of Infant Feeding Support
Maggie Redshaw, BA (Hons), PhD, and Jane Henderson, BSc (Hons), MSc
ABSTRACT: Background: Breastfeeding involves learning for women and their infants.

For emotional, social, and developmental reasons this type of feeding is recommended for all
newborn infants but for those in exceptional circumstances. The objective of this study was to
gain a better understanding of what is needed in the early days to enable women to initiate and
continue breastfeeding their infants. Methods: Data from a large-scale national survey of
womens experience of maternity care in England were analyzed using qualitative methods,
focusing on the feeding-related responses. Results: A total of 2,966 women responded to the
survey (62.7% response rate), 2,054 of whom wrote open text responses, 534 relating to infant
feeding. The main themes identified were the mismatch between womens expectations and
experiences and emotional reactions at this time, staff behavior and attitudes, and the
organization of care and facilities. Subthemes related to seeking help, conflicting advice,
pressure to breastfeed, the nature of interactions with staff, and a lack of respect for womens
choices, wishes, previous experience, and knowledge. Conclusions: Many women who succeeded felt that they had learned the hard way and some of those who did not, felt they were
perceived as bad mothers and women who had in some way failed at one of the earliest
tasks of motherhood. What women perceived to be staff perceptions affected how they saw
themselves and what they took away from their early experience of infant feeding. (BIRTH 39:1
March 2012)
Key words: breastfeeding, midwifery, postnatal support

Breastfeeding promotion is a high priority for public

health, and exclusive breastfeeding for 6 months, with
supplemental breastfeeding to 2 years of age, is recommended (1,2). However, patterns of infant feeding are
variable, even within developed country contexts. In the
2005 Infant Feeding Survey in England, initial breastfeeding occurred following 78 percent of births, but by
6 weeks this proportion had declined to 48 percent, and
at 6 months only a quarter of mothers gave any breastmilk. In 2007 a similar proportion of women in England
(80%) reported putting the baby to the breast at least
once, and three-fourths (75%) breastfed or partially

breastfed their infants for the first few days after birth
(3). A similar proportion of mothers (70%) in a 2006
United States survey were exclusively or partially
breastfeeding at 1 week, and at 4 to 6 months this proportion had also reduced to 20 percent (4). Data from
Canada collected over the same time period indicate
higher rates of initial breastfeeding (90%), just over half
of mothers (52%) doing so at 3 months and 14 percent
at 6 months, although more than half were still giving
some breastmilk (54%) at this time (5).
Breastfeeding support has commonly been seen as an
integral part of postnatal care, and women often report

Maggie Redshaw is a Senior Research Fellow and Social Scientist and

Jane Henderson is a Health Service Researcher at the Maternal Health
and Care Research Unit, National Perinatal Epidemiology Unit,
Oxford, United Kingdom.

Address correspondence to Maggie Redshaw, BA (Hons), PhD,

National Perinatal Epidemiology Unit, University of Oxford, Old
Road, Oxford OX3 7LF, UK.

The Maternal Health and Care Research Unit within the National
Perinatal Epidemiology Unit (NPEU) is funded by the Department of
Health in England. The views expressed are those of the authors and
do not necessarily reflect those of the Department of Health. The original survey was funded by the Department of Health (London, UK), the
Care Quality Commission (formerly Healthcare Commission; London,
UK), and the NHS Information Centre (London, UK).

Accepted August 4, 2011

 2012, Copyright the Authors
Journal compilation  2012, Wiley Periodicals, Inc.

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BIRTH 39:1 March 2012

needing information and feeling unsupported at this

time, frequently discontinuing breastfeeding earlier than
they would have wished (4,68). Early on, the reasons
most commonly given for stopping breastfeeding are
insufficient milk, painful breasts or nipples, and the baby
not sucking or rejecting the breast (9). In the second
week, women were also more likely to report that this
type of infant feeding took too long or was too tiring.
Using womens own words, the aim was to better understand their experience of postnatal care and support in
relation to breastfeeding, by identifying predominant
themes and reflecting on the language and constructs
used.

Methods
In a national survey of womens experience of maternity
care in England, a random sample of women who gave
birth in a week in March 2006 were selected by the
Office for National Statistics (ONS) and surveyed at
3 months after the birth (8). Structured question
response formats and some open questions were used.
Reminders were sent to nonrespondents at 2 weeks and
a further questionnaire at 4 weeks. Multi-centre
Research Ethics (MREC) approval was obtained before
the study.
Quantitative data from the survey are used to
describe the women responding and the open text
responses to two open questions used in this qualitative
analysis. The same questions, which also were used in
an earlier survey (10), were: If there was anything
about your postnatal care in hospital that you could
change, what would it be? and Is there anything
else you would like to tell us about your care while
you were pregnant or since you have had your baby?
All feeding-related responses were included in the
analysis.
In the process of qualitative analysis the responses
were read and reread separately by two researchers,
anticipated and emergent themes were identified, and
differences in interpretation were discussed (11). Initially, after reading all the responses, each was coded
under an overarching theme, and by subthemes that had
been identified and agreed upon. For the purposes of
numerical analysis, up to three predominant themes
were coded for each response. Codes were refined further as the analysis progressed in an iterative manner,
and discrepant cases were sought to illuminate the issues
(1214). In rereading the responses, new associations
were made among different facets of the analysis. The
quotations selected and discussed illustrate the themes
arising from the experience of early infant feeding and
support.

Results
The response rate to the survey was 62.7 percent representing 2,966 women. The mean age of the infants at the
time of questionnaire return was 15.5 weeks (median:
15, range: 1328 wk). Using data from the ONS sampling frame, it was possible to compare responders and
nonresponders. Compared with responders, nonresponders were more likely to live in London, be single parents,
born outside the United Kingdom, be younger, live in a
deprived area, be a student, or not state their occupation
(8).
Eighty percent of women reported putting their baby
to the breast at least once. In the first few days 59 percent of women gave breastmilk only, 16 percent breastmilk and formula, and 25 percent formula only. At the
time of the survey 26 percent of women gave breastmilk only, 17 percent breastmilk and formula, and 57
percent formula only (15). Those who responded to the
open questions were slightly more likely to be firsttime mothers, to be white, have left school after
16 years, be older, and live in more advantaged areas
(Table 1).
A total of 1,436 women (48.4%) wrote text responses
about postnatal hospital care, 254 of which (18%)
referred to one or more aspects of infant feeding, and
1,172 women responded to the Anything else you
would like to tell us question, of whom responses from
17 percent (196) related to infant feeding. The analysis
is based on these data.
Table 2 provides an overview of womens responses,
showing four broad themes, which predominantly
related to matching experiences with expectations,
staff behavior and attitudes, emotional reactions,
and the organization of care and facilities. Subthemes
related to seeking help; conflicting advice; pressure to
breastfeed; interactions with staff; and a lack of respect
for womens choices, wishes, previous experience, and
knowledge. The themes raised in response to both questions were similar and are discussed in the text.

Matching Experiences with Expectations

Expectations in relation to infant feeding support were
clearly articulated. Women described needing active
help, consistent advice and information, and care for
themselves: they both needed and expected more help
with feeding, especially breastfeeding, which involved
advice and practical help:
I am breastfeeding my now 4-month-old daughter, but nearly
gave up due to no one giving me the time to sit down and
show me what to do. (1688)

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BIRTH 39:1 March 2012

Breastfeeding needs to be established before mothers are

discharged to be observed and advice and guidance given.
Hospital walls were plastered with the benefits of breastfeeding
but nobody actually talked about it. (1988)

Some women felt undermined when they had difficulty with breastfeeding:
After my c-section, I struggled with feeding my baby during the
night because I found it hard to sit up and was exhausted and in
discomfort. I was not given much support I felt a bit of a nuisance and it was intimated I should give bottle feeds. I may have
started bottle feeding if this had been my first child. (5061)

Others reflected on their lack of experience and how

they were helped with feeding:
Every midwife had a different way of helping to breastfeed
which was very confusing. (5453)
My baby was sleeping most of the day it was my first child
I was unsure what to do. I asked one midwife if I should
waken the baby to feed and she said no . My baby
was awake all night feeding and the midwife on night
shift said I should have been feeding the baby during the day.
(1486)

Table 1. Summary of Maternal and Infant Characteristics for Survey Respondents

Characteristics
Maternal
Age (yr)
1619
2024
2529
3034
3539
40+
Age on leaving full-time education
<17 yr
1718 yr
19+ yr
Still in full-time
education
Previous births
None
One or more
Ethnicity
White
Nonwhite
Place of birth
In the United Kingdom
Outside the United
Kingdom
IMD*
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Infant
Low birthweight (<2,500 g)
Preterm (<37 completed
weeks of gestation)

Women Responding
to Open Question on
Postnatal Stay (n = 1,436)
No. (%)

Women Responding
to Open Question on
Anything Else (n = 1,172)
No. (%)

Women Not
Responding to Open
Questions (n = 902)
No. (%)

54 (3.8)
193 (13.5)
349 (24.5)
470 (33.0)
300 (21.0)
60 (4.2)

38 (2.5)
191 (12.4)
347 (22.5)
542 (35.2)
352 (22.8)
71 (4.6)

45 (5.1)
176 (19.8)
226 (25.4)
269 (30.2)
158 (17.8)
16 (1.8)

333 (23.2)
427 (29.8)
649 (45.5)
16 (1.1)

368 (23.9)
437 (28.3)
720 (46.7)
17 (1.1)

323 (36.7)
266 (30.2)
285 (32.3)
7 (0.8)

638 (46.3)
739 (53.7)

617 (41.5)
868 (58.5)

314 (36.0)
558 (64.0)

1,247 (88.2)
167 (11.8)

1,378 (89.7)
158 (10.3)

750 (84.6)
137 (15.4)

1,192 (84.7)
215 (15.3)

1,283 (84.3)
239 (15.7)

706 (81.4)
161 (18.6)

335 (23.4)
280 (19.6)
293 (20.5)
263 (18.3)
259 (18.1)

357 (23.0)
311 (20.0)
337 (21.7)
279 (18.0)
268 (17.3)

146 (16.2)
146 (16.2)
182 (20.2)
201 (22.5)
224 (26.9)

77 (5.4)
79 (5.5)

94 (6.1)
93 (6.1)

56 (6.3)
49 (5.6)

Five hundred and forty-four women responded to both open questions. Numbers indicate women providing information on the characteristics listed,
excluding missing values, and thus vary.
*Index of Multiple Deprivation (IMD) is a small area-level UK government measure with seven domains including income, employment, crime, and
health and disability.

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BIRTH 39:1 March 2012

Contradictory advice about positioning and attachment were more common when women were having
problems and had seen several midwives:
To be seen by one or as few people as possible to help with
breastfeeding. Every time I pressed my buzzer for help, a

Table 2. Overarching Themes from Open Text Responses

Relating to Infant Feeding in the Context of Maternity
Care. Number of Responses (% of Respondents who
Responded on Infant Feeding Issues)

Themes
Womens needs and
expectations
Help and support
Consistent advice
Information
Care for the women
themselves
Care for their baby
Milk supply
Theme totals
Staff behavior and attitudes
Expectation women
will breastfeed
Expectation women
will look after their
own babies
Wishes, choices, and
knowledge respected
Pressure to breastfeed
Institutional rules
Attitudes and language
Physical intervention
Theme totals
Womens emotional reactions
Anxiety and worry
Engaging in a struggle
Feeling guilty
Loneliness and isolation
Theme totals
Organization of care and
facilities
Privacy
Nutrition and meals
Staffing
Length of stay
Neonatal and
transitional care
Equipment and facilities
Theme totals
Overall totals

Postnatal
Hospital Care

Anything Else
about Care

No. (%)

No. (%)

152 (29.5)
41 (8)
29 (5.6)
20 (3.9)

118 (37.8)
27 (8.7)
19 (6.1)
5 (1.6)

8 (1.6)
7 (1.4)
257 (50)

3 (1.0)
13 (4.2)
185 (59.4)

18 (3.5)

19 (6.1)

13 (2.5)

3 (1.0)

18 (3.5)

20 (6.5)

25 (4.8)
6 (1.2)
35 (6.8)
7 (1.4)
122 (23.7)

24 (7.7)
4 (1.3)
10 (3.2)
1 (0.3)
81 (26.1)

21 (4.1)
4 (0.8)
7 (1.4)
18 (3.5)
50 (9.8)

10 (3.2)
9 (2.9)
11 (3.5)
2 (0.6)
32 (10.2)

8 (1.6)
13 (2.5)
33 (6.4)
16 (3.1)
8 (1.6)

1 (0.3)
3 (1.0)
2 (0.6)
2 (0.6)
3 (1.0)

8 (1.6)
86 (16.8)
515 (100.0)

3 (1.0)
14 (4.5)
312 (100.0)

Overall totals are greater than the number of respondents because

some womens responses were categorized under several different
themes.

different person came and told me a different way to feed my

baby, I got so confused and upset. (2228)
Advice about breastfeedingmy son and I struggled with feeding . Each change of shift saw different advice, I found this
very distressing. (2751)

First-time mothers expected to receive extra help with

feeding and general baby care:
Being a first time mum I would have liked to have been shown
how to breastfeed properly. There werent enough staff and I
was left for hours, when I was told they would be right back.
(6012)
The midwives were too quick to judge my latch-on technique
and I did not realise that my breastmilk had not come I was
exhausted and felt alone as soon as my husband left. (4849)

Conversely, multiparous women were expected to

know how to care for their baby and some felt
neglected:
As I was a second-time-around mother I was left alone. No one
checked if I was coping or all right with feeding. (4687)
Staff should have more time to spend with new mothers, helping with feeding Although this was my second baby, it
would have been reassuring to have refreshers I was left to
my own devices. (3893)

Mothers of babies born preterm or at low birthweight,

or with tongue-tie or jaundice also expected to get extra
help with feeding and infant care. If the baby was in the
neonatal unit, some women had to split their time
between the postnatal ward and neonatal unit:
I had a caesarean and my baby went to SCBU [neonatal unit]
for 4 days. I felt lost as I had to keep walking between
SCBU and the ward to breastfeed 3 hourly I missed meals
and drug rounds. (5844)

Several women wrote about how breastfeeding was

dealt with in antenatal classes. Although it was useful to
have information about the benefits of breastfeeding,
some felt it led to expectations that might not be
realized:
I feel the information on breastfeeding is unrealistic. Although
I know you want to encourage breastfeeding, the info should be
more truthful, i.e., it hurts and takes a long time to establish a
good feeding technique. It was very easy for the midwives health visitor to blame incorrect positioning but I got
mastitis twice and engorgement and I felt very alone. We are
fine now, but the leaflets and books show pictures that look so
lovely and idealistic. (2504)

Staff Attitudes and Behavior

Although some women described very positive experiences with staff, a principal area of conflict related to

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BIRTH 39:1 March 2012

breastfeeding versus bottle feeding. Most had decided to

try breastfeeding, but if they had difficulties and would
have opted to give a bottle, felt under pressure:
Breastfeeding was pushed on me. I had chosen to feed this way,
but found it very difficult. It took 2 days to get a bottle for my
baby and I felt very bullied into continuing breastfeeding even
when it was not working. (5736)

Some women felt it was not a matter of choice and

wanted their position to be understood:
I struggled a great deal . not every mother decides she wont
breastfeed for convenience. I was desperate to breastfeed but
had huge problems. (2606)
Being someone that was determined to have a natural birth and
breastfeed, an emergency CS was a shock . I found the pressure to breastfeed after my baby had been given a bottle on her
first night in SCBU was intense. (3282)
Although I have managed to successfully breastfeed I felt
that breastfeeding was almost an obsession with virtually every
health care professional I came into contact with I felt
unable to ask for advice because the approach seems to be to
keep women breastfeeding at all costsregardless of pain, discomfort, fatigue, etc.and all the guidance and support is
geared towards an ideological push for breastfeeding rather
than the wellbeing of the mother. (5121)

Staff had different attitudes and approaches, and some

women reported being made to feel guilty or inadequate
if their baby did not breastfeed well, or if they chose to
give formula. They would have liked help with formula
feeding and felt neglected compared with breastfeeding
mothers:
The midwives couldve been more supportive towards me
because my baby didnt want to breastfeed. I was made to feel
that it was my fault and was subsequently ignored. (1637)
They made me feel very guilty for being unable to do it. (3075)

Finding that staff did not always support breastfeeding came as a surprise to some women:
I had trouble starting breastfeeding, I asked a midwife to help
me but she just told me to use a bottle! (6666)

Women reported that midwives expected them to ask

for help when needed. However, they commonly felt
that breastfeeding support should be offered rather than
having to ask:
Staff were very busy, not enough time to check if (especially
first-time mums) doing OKjust pop in and ask if all OK and
take your word for it. I had not slept in 3 days and was not coping but said I was OK and was left alone. Felt I did not get any
help or support postnatallyespecially breastfeeding. (4463)
Nobody seemed to have the time to sit and help me to get my
baby to latch-on or to explain how it works. (4736)

Midwives differed from the women in their care in

the importance they attached to privacy. In multiple
occupancy areas midwives preferred to have curtains or
screens open to encourage women to look out for each
other and be sociable, but some women wished to feed
in private and explained that curtains were opened
without their permission:
Told me they preferred curtains open in the morningmidwife
opened without permission. I wanted to breastfeed in private
and to check I hadnt leaked any blood whilst in bed. There
were a lot of male partners and siblings on the ward at this
point. It was a bit off-putting. (1593)

Some women expressed their wishes on this point:

[I wanted] privacy and respect from staff, I am a nervous new
mum, and would preferred to have curtains closed round my
cubicle in the ward, but theyd walk in and leave them open for
the rest of the people on the ward to see!! (4736)

Naughty Children and Bad Mothers

Some of the quotations presented demonstrate the judgmental attitudes of staff as perceived by women
responding about infant feeding. Negative staff attitudes
or behavior ranged from women feeling bullied or
judged, being shouted at, midwives acting in a
condescending manner, being insensitive,
inconsiderate, disrespectful, and rude.
No one offered to show me how to breastfeed, bath or change
my baby, and I was shouted at for falling asleep and not feeding
the baby although he hadnt woken up either. (1599)

Some women reported being spoken to like naughty

children when they had tried to breastfeed and failed,
being reprimanded for not doing what was expected:
I made the choice not to breastfeed my baby as my attempts at
feeding my first child were unsuccessful . I was made to feel
(by some midwives) like I was a bad mother and felt that I
had somehow failed... . Is there a reason why we are made to
feel an inferior mother for making the choice to bottle feed ?
I was most upset that I couldnt feed my own child and felt that
I needed support, not criticism. I still feel like I havent given
my children the best start in life and feel like I lack something
as a mother. (3026)

Midwives and other staff could be perceived as powerful and authoritative individuals who were in control,
but not always kind or supportive:
I felt very isolated and lonely, and having a private room would
have liked my husband to be able to stay the night with me but
this was not allowed I was kept in for 2 days because I was

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BIRTH 39:1 March 2012

having trouble breastfeeding, but inconsistency of advice and a

mean school teacher approach from some midwives made
this a horrible experience. (5121)

The infantilization suggested by the language used in

these responses is reinforced by womens reports of having to ask about basics such as the location of the toilet,
mealtimes, and the rules about visiting hours and partners staying:
I was just left, when I went onto my ward I didnt have anything explained to me, I was just took to my bed by my midwife
and left, the other girls on my ward explained everything . It
was little things like where the showers and toilets were, and
where I got the milk from to feed my baby. (1565)

Some women reported feeling that they did not count,

they were just another new mum or a number, not a
person. As in the area of privacy, their wishes were not
always respected and personal space was invaded:

One midwife was offhand and unpleasant one night because my

2-day-old baby cried persistently, as if both I and my baby were
to blame. (2536)

Womens Emotional Reactions

Womens diverse responses to infant feeding and support are shown in the language used. They described
their feelings and reactions to staff and the way in which
successful or unsuccessful breastfeeding affected their
perceptions of themselves as mothers. They could feel
isolated, neglected, ignored, and lonely,
and if breastfeeding had not gone well, like a bad person or a failure who had let the baby down.
Some were anxious at being in an unfamiliar environment with strangers, felt stressed, and sometimes fearful
of their new responsibilities; others were confused or
angry about conflicting advice and the lack of support.
First-time mothers in particular lacked confidence:

Night midwives were not very goodI had trouble breastfeeding, and they were very rough and fairly unhelpful when I asked
for help. (3349)

I was unhappy as my baby didnt take to breastfeeding and I felt

humiliated Both me and the baby were distressed. (4103)

I had been breastfeeding my baby. she said he was not

latched on and grabbed my breast and pushed it into his mouth.
This was highly inappropriate and insensitive he had fed
successfully for 1 2 hour, but she refused to listen. (4673)

I suffered a few difficulties breastfeeding my baby the midwives made me feel so guilty , they left me very upset and
down about myself a midwifes job is to support a mother
and make her feel positive about herself . they should support you with what you feel is right for you. (2436)

Some staff even grabbed my breast and just pushed it inside my

babys mouth. This did not teach me how to feed my baby, it
was awful. (2228)

However, other womens emotional and practical

needs were better addressed in terms of confidence and
trust:

Relatively few women reported this type of intrusive

physical intervention, but those who did so were confused and upset by it.
Communication with and between staff about care
was an issue at times, with overt antagonism between
midwives and doctors and a critical attitude toward the
women themselves:
Some doctors, midwives, and nurses made me feel stupid when
I asked a question or talked down to me, though it was my second child. (5677)
Midwives talked loudly at night. They didnt explain the medication they gave me were always losing my notes. They
bitched about the night staff and vice-versa. They treated me
like I was stupid and didnt explain anything. Midwives didnt
hide their dislike for the doctors. (3407)

Feeling caught between groups of health professionals

worked against women feeling confident about their care
or their ability to cope and underlined the inconsistent
approach that women sometimes complained of more
directly. A single unpleasant incident sometimes marred
postnatal care:

The midwives were absolutely fantastic and helped me with

any problems that I had, such as trying to breastfeed properly,
they helped me feel more positive if I couldnt do things on
a one-to-one basis if it was needed. (3801)
Once I had had the baby I did get a tremendous amount of support from the midwives with breastfeeding I was lucky to
have a couple of great midwives whose advice I trusted. (2687)

Learning the Hard Way

Many women felt isolated, left alone, and unsupported. The tiredness and distress associated with trying
to breastfeed and feeling they were not doing very well
at what was meant to be a natural behavior overwhelmed
some women:
I was totally exhausted, scared and felt quite isolated. My baby
cried constantly and would not be put down at all . I needed
a lot of support with breastfeeding. (2156)
I was very upset that after the traumatic birth of my daughter I was just sent to a ward and my husband sent home .

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BIRTH 39:1 March 2012

just left alone with this new baby and felt very lonely and
scared . I wanted to breastfeed but struggled. (3471)

Breastfeeding specialists, counselors, or clinics are

available in some hospitals, but women might only
become aware of them after developing problems:
I already had cracked, sore nipples after 3 days and only saw
the same midwife for 1 day, then another on the next shift etc.
The breastfeeding advisor was only down the corridor and I
never knew and would have liked to have gone there myself
whilst in hospital; instead saw her at home after agony. (6231)
I was told at antenatal classes . that the hospital had a specialist breastfeeding person. However, when I asked to see her,
it fell on deaf ears. As this was my first baby, I had no experience and looked upon midwives and nurses to help me, however, I felt I had to learn the hard way (on my own). (5616)

Some groups of women needed additional help and

care, feeling that they managed to breastfeed despite
a lack of support or they could have managed had
help been available. For example, after an operative
delivery, significant blood loss, or a long labor, they
expected to receive help on the postnatal ward:
Once my baby was born I had no care or assistance with feeding nursing. As I was on a catheter I was unable to move after
my epidural and was made to feel in the way when I had to
repeatedly call for help. (2389)
I was told that because of me having pre-eclampsia and an epidural, I would get help feeding . When I asked for this . I
was spoken to rudely and left feeling very upset. (5189)

Length of postnatal stay was a concern for some:

those who would have preferred a longer stay felt they
were expected to leave as soon they were physically
well, before breastfeeding was established and, in
some cases, before they were psychologically ready to
take on the responsibility of caring for a newborn
independently:
Would have liked to stay longer to feel more confident but
felt as I was expected to go as soon as physically well enough.
It was slightly scary as first baby. (1894)

Others preferred to leave sooner, some because of

poor staffing, some because they could not get enough
sleep in hospital:
Very bad wardunderstaffed. Felt neglected. No help advice
given about breastfeeding baby care. Decided to go home same
day because standard of care so low, but would have liked to
have stayed a night if more care had been available. (2052)

Despite staffing-related issues, some women did make

positive comments about their experience of postnatal
care in hospital, although this was framed by recognition
of staffing problems:
They were so busy you felt you were being too demanding, the
staff were lovely but so overstretched. (2207)

I had inadequate care postnatal due to the lack of midwives on

duty. The midwives were always polite and courteous but were
not available all the time to give me the support I needed with
my breastfeeding. (3770)

Organizational Factors
Discussion
Staff shortages, particularly of midwives, were put forward as an explanation for poor care and negative
attitudes:
Midwives were obviously overworked and
staffed often moody and short-tempered. (3075)

under-

Women reported having to be persistent in asking for

help and waiting for long periods for help to come. Others felt that they were a nuisance asking for help so
frequently when there was clearly a shortage of staff:
Each time I asked for help I was given it, but I would have felt
much more relaxed if there was more of a presence by midwives. I realised that they were extremely busy so felt like I
didnt want to bother them. (4928)

Some women perceived staff shortages to be a particular problem at night, feeling more alone at that
time.

The data presented reflect the issues as perceived by

new mothers, many of whom initiated and continued
breastfeeding and some who did not. All of those who
responded recognized the importance of the topic for
them and their babies. They emphasized the need for
early support, help, and information, and recognized the
negative consequences for maternal self-esteem and
well-being.
The women who responded about infant feeding were
self-selected and were more likely to be older, with more
education, and of white ethnicity than women who did
not respond. They often had strong opinions and probably experienced more feeding problems. The postnatal
question was framed and designed to elicit suggestions,
with a view to collecting data that could support
improvements in the quality of care. Although many
women were critical, they also expressed positive views,
particularly at the end of the survey.

28
The responses and the analysis provide insights. The
poor treatment received by some women suggests that
there is room for change. The underlying root causes of
poor care deserve further research, but one may speculate that midwives acting in this manner are likely to be
stressed, have problems in other areas, and not likely to
be enjoying midwifery. Some responses suggested that
staff shortages may be an influential factor, others that
more effective support and advisory systems need to be
in place to help new mothers with infant feeding and
care.
This study was limited by being based on written
responses to questions in a survey. In an interview,
probes can be used to explore the issues raised. However, women may give more forthright and honest
answers to a survey without feeling the need to convey a
positive image to the interviewer. Moreover, it was possible to look at the views of a much greater number of
women than would have been possible using other methods. Peer examination, in which the research process
and outcomes are discussed in an iterative way with
another researcher, increased the validity of the coding
and themes identified. Transferability of the findings can
to some extent be assessed from the detailed description
of the sample given in Table 1.
A summary of the literature on feeding support noted
the importance of consistent advice and information,
practical support, and respect for body boundaries (7).
When breastfeeding is a technically managed activity
and a hands-on approach used to attach the baby to
the breast, they may undermine womens confidence in
their own ability. The problem of conflicting advice has
been emphasized in another qualitative study (16) and in
these analyses. Another study highlighted the importance of time constraints on staff trying to provide a high
standard of care (17). In postnatal care, midwives and
nurses often do not have time to form relationships with
women, leading to labeling and stereotyping of the kind
that some women felt was in operation here. Some
women thought that staff saw them as bad mothers,
and some took on this identity, echoing other observations of breastfeeding women and health professionals
showing that for women breastfeeding is generally equated with being a good mother (18). A qualitative
study examining the association between breastfeeding
and depression noted the devastating effect of unfulfilled
expectations when women had difficulties breastfeeding,
and described the unsupportive, bossy, and judgmental
attitudes of some staff (19).
These study findings are consistent with the literature
described and with that arising in different country contexts (20,21). Women reflected on their own expectations and needs and their emotional and physical
vulnerability, with accounts of inconsistent advice, a
lack of postnatal support, and judgmental attitudes that

BIRTH 39:1 March 2012

could affect the way they saw themselves as a mother, at

least for a time. Responding to the open question about
postnatal care, one mother, herself a nurse reminds us of
the need for basic care and communication:
I would not leave a new mother with stitches, sitting behind
closed curtains for hours and hours without any kind of contact.
I would not assume that because the patient is a nurse that she
does not require support with breastfeeding. I would ask how
she was and if she needed any more pain relief. (4642)

Implications for Practice

The qualitative data and the constructs that women used
in describing their experience emphasize the importance
of treating them as individuals and being aware of what
they may take away from the postnatal experience of
infant feeding. Women would prefer information given
in antenatal classes to be honest and realistic. Without
putting them off, it should be made clear that breastfeeding is a skill that needs to be learned by women and their
infants, which can take time. Postnatal wards are often
understaffed, and women need to be prepared to ask for
help if they need it. The reality of the situation in many
maternity units, the limited postnatal support once home,
and information about postnatal groups and peer support
should also be mentioned. Peer support, both formal and
informal, has the potential to make a difference in this
context, particularly when targeted (22).
All midwives and nurses working with postnatal
women need ongoing training in breastfeeding support
to facilitate consistent advice and practical help, and to
foster a positive can-do attitude more broadly. The
role of lactation consultants could be more fully implemented, and a breastfeeding champion in each maternity unit could work with staff and parents. Routine
audit of training would help ensure that training objectives are met and that women get the support they need
at this crucial time.

Conclusions
Many of the women who succeeded felt that they had
learned the hard way, and some of those who did not,
felt they were perceived as bad mothers and women
who had in some way failed at one of the earliest
tasks of motherhood. What women perceived to be staff
perceptions affected how they saw themselves and what
they took away from their early experience of infant
feeding. Women would prefer information given in
pregnancy to be realistic rather than idealistic. Midwives
working with postnatal women need ongoing training in
breastfeeding to enable them to support women
effectively.

29

BIRTH 39:1 March 2012

Acknowledgments
The authors wish to give many thanks to the women
who participated in the survey.

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