Elsevier

Midwifery

Volume 22, Issue 4, December 2006, Pages 365-376
Midwifery

‘Breaking the rules’ in baby-feeding practice in the UK: deviance and good practice?

https://doi.org/10.1016/j.midw.2005.12.005Get rights and content

Summary

Objective

to discover the views of midwives in relation to baby feeding.

Design and method

qualitative using grounded theory. Data collection used in-depth interviews with 30 midwives who volunteered to participate. Field notes of the interaction between the researcher and participant were also recorded as data. The constant comparison process was used to generate codes and subsequent conceptualisations from the data.

Setting

two maternity units in the North of England, UK.

Findings

the core category of this study is called ‘surviving’ baby feeding, and the findings reported here are a significant theme that emerged. These midwives described a management strategy termed ‘breaking the rules’ for supporting mothers with baby feeding. The concept ‘breaking the rules’ represented practices that were not congruent with evidence-based, baby-feeding policy and recommendations, or with some practices that were usual in the local working environment. These midwives were aware of their actions but described how they ‘hid’ their behaviour from mothers and from their peers. Some of the behaviour described showed that these midwives ‘broke the rules’ in relation to professional requirements and the facilitation of informed decision making about feeding practices with the women in their care. However, some midwives reported examples of practice that is woman-centred, and supportive of baby feeding, but this was not acceptable to others in the working environment.

Key conclusions and implications for practice

deviant behaviour was described by these midwives in relation to informed decision making and options for mothers in baby-feeding practice. These midwives ‘knowingly concealed’ their deviant practices from others. These behaviours should be taken seriously as they risk being negligent in relation to UK statutory professional requirements. However, practices that depart from those that are normal in the local working environment are not always negative and detrimental to the recipients of care; they can be positive. There needs to be more research, open discussion and debate about midwifery practice that does not always ‘fit in’ with professional, and ‘normal’ expectations.

In this study, the term ‘baby feeding’ relates to how babies’ nutritional needs are met.

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.

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