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Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / s r h c
A two-decade perspective on mothers’ experiences and feelings related to breastfeeding initiation in Sweden ☆ Karin S.M. Holmberg a, Ulla M.C. Peterson a,b, Marie G. Oscarsson a,c,* a b c
Department of Health and Caring Sciences, Linnaeus University, Sweden Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden Department of Public Health and Caring Sciences, Uppsala University, Sweden
A R T I C L E
I N F O
Article history: Received 11 November 2013 Received in revised form 4 April 2014 Accepted 10 April 2014 Keywords: Breastfeeding Initiation Mothers’ experiences Baby Friendly Hospital Initiative
A B S T R A C T
Objective: The purpose was to examine mothers’ experiences and feelings related to breastfeeding initiation from a two-decade perspective. Methods: A repeated cross-sectional survey was conducted at a maternity ward before and after introduction of Baby Friendly Hospital Initiative (BFHI) and in a follow-up survey. Women participated in 1992 (n = 83), 1993 (n = 74) and 2011 (n = 94). Results: The duration of time at the first suckling differed; in 2011, the baby sucked 24.4 minutes compared to 12.7 minutes in 1992 (p < .001) and 13.6 minutes in 1993 (p < .001). In 1992, 34.6% of the women reported using supplementary formula compared with 5.9% in 1993 and 9.3% in 2011 (p < .001). The mothers’ contacts with the child or the father as well as their moods did not vary during the years. Mothers rated their feelings towards breastfeeding as being lower in 2011 than in 1992 and 1993 (p = .008). In 2011, mothers experienced breastfeeding as being more difficult and reported a higher degree of tension, insecurity and anxiety. Conclusions: Supplementation was given to healthy newborn infants, which does not conform to BFHIs intentions. Routines and support in relation to breastfeeding initiation need to be continuously evaluated in order to strengthen and sustain the BFHI. © 2014 Elsevier B.V. All rights reserved.
Introduction Successful long-term breastfeeding depends on a successful start. With this in mind, the Baby Friendly Hospital Initiative (BFHI) was launched by UNICEF and the WHO in 1991 [1,2]. The initiative is a global effort to implement practices that protect, promote and support breastfeeding initiation in maternity services. The “Ten Steps to Successful Breastfeeding” is the underpinning framework of the BFHI and summarises the maternity practices necessary to support breastfeeding. The Swedish government decided in 1992 to encourage Swedish hospitals to participate in the BFHI, including the “Ten Steps to Successful Breastfeeding.” In 1997, all maternity services were assessed and accredited as “baby-friendly.” In the period following this implementation, breastfeeding rates increased on a national level, most likely resulting from adherence to the “10 Steps”
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Authors’ contributions: KH participated in the design of the study 1991. MO and KH designed the study 2011. KH collected all data 1992 and 1993. MO and UP performed the statistical analysis. MO, UP and KH wrote the manuscript. All authors read and approved the final manuscript. * Corresponding author. Tel.: +46 480 446080. E-mail address: [email protected] (M.G. Oscarsson).
and a Baby Friendly climate. Today, the frequency of breastfeeding in Sweden is high. Almost 97% of infants born in 2010 were breastfed at the age of 1 week, and at 6 months, 62% were exclusively or partially breastfed [3]. The Swedish government’s recommendation is that exclusive breastfeeding should be practised during the first 6 months [3]. Thereafter, breastfeeding should continue with the addition of complementary foods. In Sweden, antenatal, intrapartal and postnatal care as well as breastfeeding support is primarily provided by midwives. If complications occur, they cooperate with obstetricians, under a sharedcare model, where both midwives and obstetricians have the joint responsibility. Breastfeeding counselling is provided both individually and in parenting classes during pregnancy and postpartum. In the setting where this study was performed, antenatal care was conducted in healthcare centres in municipalities. Labour and maternity wards were situated at the hospital and midwives had a rotating schedule, which means that they alternate between both wards. During the last few decades, routines regarding normal childbirth have changed. According to standard labour routines in 1992, healthy newborns were swaddled in a blanket and placed on the mother’s chest. The child was allowed to breastfeed for 5 minutes to minimise sores on the mother’s nipples. At maternity wards, both single and four-bedded rooms existed. Nurseries were present and
http://dx.doi.org/10.1016/j.srhc.2014.04.001 1877-5756/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Karin S.M. Holmberg, Ulla M.C. Peterson, Marie G. Oscarsson, A two-decade perspective on mothers’ experiences and feelings related to breastfeeding initiation in Sweden, Sexual & Reproductive Healthcare (2014), doi: 10.1016/j.srhc.2014.04.001
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rooming-in at daytime was an option. Partners and siblings could visit the ward twice a day for 2–3 hours each time. The average hospital stay for mothers was 4–5 days. Before the introduction of BFHI, a training programme was designed and continuing education of health professionals was implemented. In 1993, all healthy newborns were placed skin-to-skin with their mothers as soon as possible after birth and remained there until the first suckling was established. The mothers stayed at the labour ward for at least 2 hours after birth. Maternity ward had single rooms, where partners and siblings had the opportunity to stay with the mother and the newborn. Rooming-in was common practise, and a written breastfeeding policy was developed. The family stayed for up to 72 hours after birth. In 2011, the same conditions were still in practise, but the average stay for women with normal birth had decreased to 2 days. In 1993 and 2011, parents and their newborn were invited to return to the maternity reception about 2–3 days after birth and to postnatal care 6–12 weeks after birth. There, they met a midwife who had experience in both postnatal care and breastfeeding. In addition, parents had regular contact with a nurse in child healthcare. Based on the “Ten Steps to Successful Breastfeeding” [1,2], early initiation of breastfeeding is important, as it is associated with longterm breastfeeding [4,5]. Other factors which influence breastfeeding positively include: skin-to-skin contact [6], continuity of care [7], support from partner, family and health professionals [8–11], being exclusively breastfed in hospital [12,13] and breastfeeding on demand [14]. Additionally, rooming-in is recommended as it promotes mother–child interaction and the likelihood of long-term breastfeeding [15,16]. Since the BFHI was introduced worldwide, several studies have evaluated its impact on breastfeeding rates from a healthcare perspective [17,18]. However, as far as we know, evaluation of the mothers’ perspective of the breastfeeding initiation is limited. Therefore, the aim of this study was to examine mothers’ experiences and feelings related to breastfeeding initiation from a two-decade perspective. Specific research questions were: Are there any differences in mothers’ experiences of breastfeeding when comparing results from 1992, 1993 and 2011? Are there any differences in mothers’ feelings about breastfeeding when comparing results from 1992, 1993 and 2011?
questionnaire at the maternity ward the day after the birth. The completed questionnaire was returned in an enclosed envelope when they left the maternity ward. A questionnaire was developed based on “Ten Steps to Successful Breastfeeding.” The questionnaire was constructed to evaluate the BFHI at the hospital. Results from the questionnaires that were collected in 1992 and 1993 have not been published until now. In the 2011 version, a group of staff members involved in providing breastfeeding support affirmed the content validity. They evaluated which questions were still relevant. A pilot study was performed among 16 mothers at a maternity ward in order to achieve face validity. They were asked to assess the questionnaire and indicate if they had any difficulty in responding to the questionnaire or if there were any cases of ambiguity. This resulted in minor corrections. From the questionnaire, 32 items were presented in this study. They are grouped into four areas: 1) six questions relating to background characteristics; 2) five questions about the first suckling occasion at the delivery ward; 3) three questions about their experiences of breastfeeding during their first day at the maternity ward; 4) mothers’ feelings related to the breastfeeding initiation were rated using the Alliance Scale [19] psychometric, which was tested in 2010. The scale had been used previously [20] but had not been tested for reliability and validity until 2010 [19]. At that point, it was named “Alliance Scale” due to its ability to rate mothers’ relation to their child and to the father. The scale takes only a few minutes to complete, which makes it easy to use. It has 18 items covering five dimensions concerning: mothers’ contact with child (four items), mothers’ contact with father (four items), mothers’ feelings towards breastfeeding, comfort (two items), mothers’ feelings towards breastfeeding, calm (five items) and mothers’ mood (three items) (Table 1). A semantic differential scale with response alternatives ranging from 1 to 7 was used with extreme expressions at each end; no figures were given. The endpoint sometimes represented a positive assessment and sometimes a negative assessment, thus, avoiding routine-like responses. Reliability coefficients were satisfactory (>.7) in all dimensions. Cronbach’s alpha was as follows: mothers’ contact with child was .79, mothers’ contact with father was .91, mothers’ feelings towards breastfeeding, comfort was .68, mothers feelings towards breastfeeding, calm was .87 and mothers’ mood was .83.
Methods A hospital in the south-east of Sweden was BFHI accredited in 1993. The hospital is an academic teaching hospital serving primarily middle class families. A repeated cross-sectional survey was conducted in 1992 and following the implementation of BFHI in 1993. In 2011, we repeated the survey once again. Participants Inclusion criteria for the study were: women with a normal vaginal birth, vacuum extraction for maternal indication and breech birth, having given birth to a full-term, healthy singleton infant, Apgar score of 9–10 after 5 minutes, good understanding of the Swedish language and being able to fill in a questionnaire. All women who fulfilled the inclusion criteria were invited to participate. In 1992, 83 women agreed to participate; in 1993, 74 women; and in 2011, 94 women. The women were recruited for 10 weeks in 2011. Response rates were 85.5% in 1992, 71.8% in 1993 and 89% in 2011. Study design and questionnaire The procedures for the surveys in all three studies were similar. All women received oral information about the study. Those women who gave informed consent were given written information and a
Table 1 Dimensions and included items. Contact with child Distant–Close Cold–Warm Insecure–Secure Difficult–Easy Contact with father Distant–Close Cold–Warm Insecure–Secure Difficult–Easy Mother’s feelings towards breastfeeding, calm Insecurity–Self-confidence Have to learn–Self-taught Difficult–Easy Tension–Relaxation Anxiety–Calm Mother’s feelings towards breastfeeding, comfort Constraint–Freedom Discomfort–Pleasure Mother’s mood Sad–Cheerful Unhappy–Happy Gloomy–Elated
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Table 2 Background factors of the participating women.
Age mean (SD)
Mothers 1992 (n = 83)
Mothers 1993 (n = 74)
Mothers 2011 (n = 94)
p-value
28.8 (SD 4.5)
27.5 (SD 4.9)
28.9 (SD5.3)
0.141
n (%) Education Primary school Secondary school College/university Parity Nulliparous Parous Born Sweden Other country Delivery Partus Normalis Breech Vacuum extraction Other Pain reliefa Epidural Nitrous oxide Acupuncture TNS Bath Pethidineb Other pain relief No pain relief Sex, child Male Female a b
n (%)
n (%) 0.000
9 (10.8) 48 (57.8) 22 (26.6)
13 (17.8) 47 (64.4) 13 (17.8)
5 (5.3) 36 (38.3) 53 (56.4)
34 (41.0) 49 (59.0)
28 (37.8) 46 (62.2)
49 (52.1) 45 (47.9)
81 (97.6) 1 (1.2)
73 (98.6) 1 (1.4)
88 (93.6) 6 (6.4)
77 (92.8) 1 (1.2) 4 (4.8) 0
73 (98.6) 0 (1.0) 0 (1.0) 1 (1.4)
92 (97.9) 0 2 (2.1) 0
15 (18.1) 47 (56.6) 0 0 0 10 (12.0) 16 (19.3) 24 (28.9)
10 (13.5) 55 (74.3) 0 2 (1.9) 0 10 (13.5) 34 (45.9) 13 (17.6)
33 (35.1) 85 (90.4) 23 (24.5) 5 (5.3) 37 (39.4) – 9 (9.6) 2 (2.1)
30 (36.1) 52 (62.7)
36 (48.6) 38 (51.4)
38 (40.4) 56 (59.6)
0.139
0.086
0.337
0.002 0.000 0.000 0.059 0.000 – 0.000 0.000 0.300
More than one option. Pethidine was not in use 2011.
The Regional Ethics Committee for Human Research, Faculty of Health Sciences, Linkoping University, Sweden, approved the study in 1991 (Dnr 92148). The Committee for Research Ethics in south-eastern Sweden approved the study in 2009 (Dnr EPK 372009).
Forsythe test was used. Data were entered and analysed with the IBM Statistical Package for Social Sciences SPSS 20.0. Findings Background factors
Analysis Differences between groups in categorical variables were tested by Kruskal–Wallis, and one-way analysis of variance (ANOVA) was used for others. Because of low internal dropout, missing values were excluded from the analyses. The endpoints of the semantic differential scale were recoded to obtain all the positive assessments at the higher endpoint. Cronbach’s alpha was used to assess internal consistency coefficients for the four dimensions of mothers’ feelings related to breastfeeding initiation (Table 1). Average scores for each dimension were calculated and differences between groups were tested by one-way ANOVA with Tukey’s post hoc test. In the event of statistically significant homogeneity of variance, the Brown–
As shown in Table 2, the three groups differed regarding education. There were twice as many mothers who had college/ university education in 2011 compared to the earlier years. The use of pain relief methods had also changed. The women used epidural, nitrous oxide and non-pharmacological pain relief methods to a higher extent in 2011. The use of Pethidine had ceased in 2011. Mothers’ experiences of their child’s first suckling and breastfeeding at maternity ward As shown in Table 3, the time before the baby sucked on the breast for the first time after birth was about 1 hour at all
Table 3 First suckling at delivery ward.
Time (minutes) between delivery and first suckling (mean, SD) Duration (minutes) of first suckling (mean, SD) Did the child attach to the nipple by him/herself? N(%) Yes No Did the child end the first suckling by him/herself? N(%) Yes No How do you estimate the child’s first suckling? N(%) Bad Both good and bad Good
Mothers 1992 (n = 83)
Mothers 1993 (n = 74)
Mothers 2011 (n = 94)
p-value
63.8 (91.7) 12.7 (12.1)
68.7 (119.5) 13.6 (13.1)
55.6 (87.1) 24.4 (21.0)
0.697 0.000 0.396
40 (50.0) 40 (50.0)
42 (58.3) 30 (41.7)
55 (59.8) 37 (40.2)
41 (52.6) 37 (47.4)
52 (70.3) 22 (29.7)
72 (78.3) 20 (21.7)
6 (7.4) 10 (12.3) 65 (80.3)
8 (11.0) 12 (16.4) 53 (72.6)
2 (2.2) 10 (10.8) 81 (87.0)
0.001
0.049
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Table 4 Differences in mean scores of mothers’ feelings towards breastfeeding initiation between the three groups (analysis of variance, ANOVA).
Contact with child Contact with father Feelings towards breastfeeding, calm Feelings towards breastfeeding, comfort Mood
Mothers 1992 (n = 83)
Mothers 1993 (n = 74)
Mothers 2011 (n = 94)
Mean (SD)
Mean (SD)
Mean (SD)
6.70 (0.5) 6.78 (0.5) 5.91 (1.0) 5.99 (1.0) 6.23 (1.0)
6.65 (0.7) 6.71 (0.9) 5.93 (1.0) 6.00 (1.2) 6.34 (0.9)
6.66 (0.5) 6.65 (0.8) 5.31 (1.3) 6.13 (1.0) 6.49 (0.9)
measurement occasions. However, the duration during the first nursing time varied; in 2011, the baby sucked almost twice as long compared with 1992 and 1993 (p < .000 and p < .000, respectively). The baby ended the first sucking on his/her own to a greater extent in 1993 and 2011 compared with 1992. The post hoc analysis showed a statistically significant difference between 1992 and 1993 (p = .047), and between 1992 and 2011 (p = .010). On the maternity ward, the women were asked to estimate the number of hours they had slept, the frequency of breastfeeding and the use of supplementation, formula or water during the first day, i.e. the day after birth. The results showed no differences in sleep duration for the 3 study years: 5.2 hours (SD 3.1) for 1992, 6.1 hours (SD 2.8) for 1993 and 5.4 hours (SD 2.6) for 2011 (p = .112). Regarding breastfeeding frequency per day, results showed a linear increase. On average, mothers breastfed 6.1 times (SD 2.2) in 1992, 7.1 times (SD 2.7) in 1993 and 8.0 times (SD 4.2) (p < .001) in 2011. Moreover, the post hoc analysis showed a statistically significant difference between 1992 and 2011 (p < .001). Results regarding supplementation indicated that the use of supplementation for the infants on the first day had changed. In 1992, 34.6% of the women reported supplementary use compared to 5.9% in 1993 and 9.3% in 2011 (p < .001). Mothers’ feelings related to the breastfeeding initiation Mothers rated their feelings towards breastfeeding using the Alliance scale. Their contacts with the child or the father did not differ during the years; neither did their mood. There were differences between the groups concerning the measure “mothers’ feelings . . . calm” as shown in Table 4. When comparing the separate items in the dimensions, mothers experienced breastfeeding as being more difficult (p < .001), and reported a higher degree of tension (p = .010), insecurity (p = .003) and anxiety (p < .001) in 2011 compared with 1992 and 1993 (Table 5).
p-value
0.856 0.501 0.000 0.672 0.191
Discussion The results indicate that over the study period, the mothers’ experiences related to breastfeeding initiations are partly consistent with BFHI. This leans towards increased respect for the recommendations given by the BFHI and the “Ten Steps to Successful Breastfeeding” [1,2]. One deviation is that supplementation is given to healthy newborn infants. Mothers also experienced breastfeeding as being more difficult and reported a higher degree of tension, insecurity and anxiety in 2011 compared with 1992 and 1993. When comparing labour ward routines, we found that the BFHI led to some important changes. In 1993 and 2011, the infant was placed skin-to-skin with his/her mother as soon as possible after birth. The first hours of skin-to-skin contact is of importance for the development of the child’s self-regulation and for maternal sensitivity [6]. When babies get to develop their rooting and tongue reflexes undisturbed, they learn to use them and do not need any help at the breast. Seminal works in this field [21,22] have shown that it takes approximately 50 minutes for the baby to find his/her way to the breast and start sucking if he/she lays naked on the mother’s breast directly after birth. The baby sucks for about 20 minutes if he/she gets to nurse freely [22]. The babies in the 2011 arm of our study came closest to the findings of these studies. Significant findings regarding labour ward routines indicate that during the two decades, the average duration of the first suckling was longer in 2011, namely, about 24 minutes. Another positive outcome in our study was that the infant stopped nursing by him/herself to a greater extent in 2011. These findings indicate that the labour ward routines take into consideration the inborn abilities of the infant and an understanding of the mothers’ need to learn to respond to this without undue interference. Although routines have changed over the years and midwives are more aware of the importance of the child’s first suckling, other factors may have influenced the routines. One such factor could be that the pain relief methods used have changed
Table 5 Differences in mean scores of mothers’ feelings towards breastfeeding between the three groups (analysis of variance, ANOVA).
Insecurity–Self-confidence Discomfort–Pleasure Constraint–Freedom Anxiety–Calm Tension–Relaxation Difficult–Easy Have to learn–Self-taught
Mothers 1992 (total n = 83)
Mothers 1993 (total n = 74)
Mothers 2011 (total n = 94)
Mean (SD)
Mean (SD)
Mean (SD)
6.06 (1.2) 6.30 (0.9) 5.69 (1.5) 6.33 (0.9) 6.22 (0.9) 5.94 (1.2) 5.06 (1.8)
5.97 (1.3) 6.24 (1.1) 5.75 (1.5) 6.37 (1.0) 6.24 (1.2) 5.94 (1.3) 5.19 (1.7)
5.39 (1.6) 6.40 (1.1) 5.86 (1.3) 5.72 (1.4) 5.76 (1.3) 5.08 (1.4) 4.59 (1.9)
p-value
0.003*,** 0.591 0.746 0.000*,** 0.010*,** 0.000** 0.088
Insecurity–Self-confidence 1992 and 2011 (p < 0.005), 1993 and 2011 (p < 0.023). Anxiety–Calm 1992 and 2011 (p < 0.002), 1993 and 2011 (p < 0.002). Tension–Relaxation 1992 and 2011 (p < 0.023), 1993 and 2011 (p < 0.24). Difficult–Easy 1992 and 2011 (p < 0.000), 1993 and 2011 (p < 0.000). * Brown Forsythe. ** Post hoc analysis: showed differences between.
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during the past two decades. For example, Pethidine is no longer used as a pain medication. When it was used, it affected the child’s alertness. Since 1996, in Sweden, epidurals have been used on a larger scale and on average, 50% of all primiparas had epidural anaesthesia during labour in 2011. It is shown that women who received epidural breastfed their children to a lesser extent during the first week after birth [23], and that infants whose mothers had received labour analgesia showed less alertness after birth [24]. The fact that the use of Pethidine has ceased cannot be the only explanation for the positive outcome of first suckling. Basically, the “Ten Steps to Successful Breastfeeding” [1,2] are still adhered to. However, step 6 concerning supplementation is still complicated. The maternity ward changed their practice and introduced rooming-in and breastfeeding on demand in 1993. A successful decline in the usage of formula was shown from 1992 to 1993; however, there was a tendency towards an increase in giving extra formula in our results from 2011. The amount or kind of supplementation could not be inferred from the study. Neither could medical indication. However, an increase in usage of formula is somewhat surprising given that only mothers who gave birth to a fullterm, healthy singleton infant were included in the study. When BFHI was introduced, health professionals were trained and breastfeeding discussions were in focus. Perhaps, breastfeeding has been taken for granted lately and the promotion of breastfeeding neglected. To be accredited or remain accredited as a BFH, it is not enough to just show high frequency of nursing; all ten steps need to be fulfilled. Our study demonstrates the need for evaluation of the BFHI as well as whether there is compliance with the recommendations. Continuous education and training of healthcare professionals is needed in order to gain an understanding of the importance of not giving supplements. In our study, mothers rated their feelings towards breastfeeding positively, but to a lower extent in 2011. The reasons why mothers’ feelings towards breastfeeding have changed are not investigated in this study; however, breastfeeding is affected by the mothers’ social situation, as well as their physical and psychological status [25–27]. The women in our study may also have been influenced by the equality debate that has been going on in Sweden over the past decade, where breastfeeding has been described in the media as being somewhat tedious, difficult and fraught with problems. In public places, lactating women have had to put up with being directed to remote rooms while breastfeeding. In social media, benefits of breastfeeding have been questioned and bottle-feeding has been portrayed as a choice one makes in an equal couple relationship. Whether or not breastfeeding continues or succeeds is also a result of health providers’ attitudes and approaches [11,13]. When breastfeeding is discussed in antenatal care and parenting groups, it is important to give a nuanced image of breastfeeding. If breastfeeding is described as a natural process that follows childbirth, mothers can perceive it as easy, which can invoke an unrealistic and idealised image [12]. At a time when mothers feel insecure and anxious about breastfeeding, the need for support must be addressed. In Sweden, most clinics have a written breastfeeding policy, which contributes to building consensus throughout the continuum of care. Midwives’ duties are to promote breastfeeding through the entire continuum of maternal healthcare, intrapartal care and postnatal care. Despite the existence of a breastfeeding policy, several changes have occurred during the last decade. The parent’s visits to antenatal care and parental classes have changed in both form and frequency, e.g. the number of visits to antenatal care has decreased for women with normal pregnancies. Similarly, many antenatal clinics only offer parental classes to primiparous women. This may have contributed to the fact that support for breastfeeding has diminished in relation to medical concerns. Another change is mother’s short length of stay at maternity wards. Nowadays, they stay only 1–2 days compared to previously
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when the mothers stayed until breastfeeding was established. The new parents have to gather a lot of knowledge and skills about breastfeeding during their short time at the maternity ward while at the same time going through an emotionally turbulent period. However, we are not suggesting an extension of the time spent at the maternity ward. Research [28] shows that early discharge is the best option for the mother and the baby. Nonetheless, when early discharge was introduced, the intention was to promote activities in order to support the woman and her partner. Specific follow-up is already established but may not be sufficient. Perhaps it is time to examine how the follow-up breastfeeding activities have functioned in this manner. Study limitations A limitation of the study is that the group of mothers studied in 2011 were different from those that gave birth 20 years ago. During this 20-year period, the level of education has increased. More women have college and university examinations. Studies [27,29] have demonstrated that higher education levels and older mothers are factors that influence breastfeeding positively. This cannot be related to the differences in the studies selection. The questionnaire is both a limitation and strength in this study. It was developed in 1991 and constructed based on the issues present during that time; however, major changes have taken place in maternity care since then. Today, many factors are obvious such as putting the baby to the breast after birth and rooming-in. On the other hand, using the same questionnaire allows us to make comparisons. Finally, the questionnaire has been tested psychometrically showing that reliability and content validity was satisfactory. Conclusion The mothers’ experiences related to breastfeeding initiations are partly consistent with recommendations given by the BFHI. The infant was placed skin-to-skin with his/her mother as soon as possible after birth and was breastfed freely. However, supplementation was given to healthy newborn infants, which does not conform to BFHIs intentions. Additionally, the mothers experienced breastfeeding as being more difficult and reported a higher degree of tension, insecurity and anxiety in 2011 compared with 1992 and 1993. Hospitals accredited as BFHI need to continuously evaluate their compliance with the standards. This would allow for an assessment of which routines need to be reviewed or revised. Conflict of interest No conflicts of interest have been declared. Acknowledgements The authors want to thank the participating women and Linda Lännqvist for data collection 2011. We are also grateful to Meena Strömqvist who revised the English. We acknowledge financial support from the Medical Research Council of Southeast Sweden. References [1] WHO/UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Geneva: World Health Organization; 1989. [2] Kyenkya-Isabirye M. UNICEF launches the Baby-Friendly Hospital Initiative. MCN Am J Matern Child Nurs 1992;17(4):177–9. [3] Socialstyrelsen. Amning och föräldrars rökvanor föräldrar födda 2011 [Breastfeeding and smoking habits among parents of infants born 2011]. Sweden: National Board of Health and Welfare; 2013. [4] Ekström A, Widström A, Nissen E. Duration of breastfeeding in Swedish primiparous and multiparous women. J Hum Lact 2003;19(2):172–8.
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Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / s r h c
A two-decade perspective on mothers’ experiences and feelings related to breastfeeding initiation in Sweden ☆ Karin S.M. Holmberg a, Ulla M.C. Peterson a,b, Marie G. Oscarsson a,c,* a b c
Department of Health and Caring Sciences, Linnaeus University, Sweden Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden Department of Public Health and Caring Sciences, Uppsala University, Sweden
A R T I C L E
I N F O
Article history: Received 11 November 2013 Received in revised form 4 April 2014 Accepted 10 April 2014 Keywords: Breastfeeding Initiation Mothers’ experiences Baby Friendly Hospital Initiative
A B S T R A C T
Objective: The purpose was to examine mothers’ experiences and feelings related to breastfeeding initiation from a two-decade perspective. Methods: A repeated cross-sectional survey was conducted at a maternity ward before and after introduction of Baby Friendly Hospital Initiative (BFHI) and in a follow-up survey. Women participated in 1992 (n = 83), 1993 (n = 74) and 2011 (n = 94). Results: The duration of time at the first suckling differed; in 2011, the baby sucked 24.4 minutes compared to 12.7 minutes in 1992 (p < .001) and 13.6 minutes in 1993 (p < .001). In 1992, 34.6% of the women reported using supplementary formula compared with 5.9% in 1993 and 9.3% in 2011 (p < .001). The mothers’ contacts with the child or the father as well as their moods did not vary during the years. Mothers rated their feelings towards breastfeeding as being lower in 2011 than in 1992 and 1993 (p = .008). In 2011, mothers experienced breastfeeding as being more difficult and reported a higher degree of tension, insecurity and anxiety. Conclusions: Supplementation was given to healthy newborn infants, which does not conform to BFHIs intentions. Routines and support in relation to breastfeeding initiation need to be continuously evaluated in order to strengthen and sustain the BFHI. © 2014 Elsevier B.V. All rights reserved.
Introduction Successful long-term breastfeeding depends on a successful start. With this in mind, the Baby Friendly Hospital Initiative (BFHI) was launched by UNICEF and the WHO in 1991 [1,2]. The initiative is a global effort to implement practices that protect, promote and support breastfeeding initiation in maternity services. The “Ten Steps to Successful Breastfeeding” is the underpinning framework of the BFHI and summarises the maternity practices necessary to support breastfeeding. The Swedish government decided in 1992 to encourage Swedish hospitals to participate in the BFHI, including the “Ten Steps to Successful Breastfeeding.” In 1997, all maternity services were assessed and accredited as “baby-friendly.” In the period following this implementation, breastfeeding rates increased on a national level, most likely resulting from adherence to the “10 Steps”
☆
Authors’ contributions: KH participated in the design of the study 1991. MO and KH designed the study 2011. KH collected all data 1992 and 1993. MO and UP performed the statistical analysis. MO, UP and KH wrote the manuscript. All authors read and approved the final manuscript. * Corresponding author. Tel.: +46 480 446080. E-mail address: [email protected] (M.G. Oscarsson).
and a Baby Friendly climate. Today, the frequency of breastfeeding in Sweden is high. Almost 97% of infants born in 2010 were breastfed at the age of 1 week, and at 6 months, 62% were exclusively or partially breastfed [3]. The Swedish government’s recommendation is that exclusive breastfeeding should be practised during the first 6 months [3]. Thereafter, breastfeeding should continue with the addition of complementary foods. In Sweden, antenatal, intrapartal and postnatal care as well as breastfeeding support is primarily provided by midwives. If complications occur, they cooperate with obstetricians, under a sharedcare model, where both midwives and obstetricians have the joint responsibility. Breastfeeding counselling is provided both individually and in parenting classes during pregnancy and postpartum. In the setting where this study was performed, antenatal care was conducted in healthcare centres in municipalities. Labour and maternity wards were situated at the hospital and midwives had a rotating schedule, which means that they alternate between both wards. During the last few decades, routines regarding normal childbirth have changed. According to standard labour routines in 1992, healthy newborns were swaddled in a blanket and placed on the mother’s chest. The child was allowed to breastfeed for 5 minutes to minimise sores on the mother’s nipples. At maternity wards, both single and four-bedded rooms existed. Nurseries were present and
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Please cite this article in press as: Karin S.M. Holmberg, Ulla M.C. Peterson, Marie G. Oscarsson, A two-decade perspective on mothers’ experiences and feelings related to breastfeeding initiation in Sweden, Sexual & Reproductive Healthcare (2014), doi: 10.1016/j.srhc.2014.04.001
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rooming-in at daytime was an option. Partners and siblings could visit the ward twice a day for 2–3 hours each time. The average hospital stay for mothers was 4–5 days. Before the introduction of BFHI, a training programme was designed and continuing education of health professionals was implemented. In 1993, all healthy newborns were placed skin-to-skin with their mothers as soon as possible after birth and remained there until the first suckling was established. The mothers stayed at the labour ward for at least 2 hours after birth. Maternity ward had single rooms, where partners and siblings had the opportunity to stay with the mother and the newborn. Rooming-in was common practise, and a written breastfeeding policy was developed. The family stayed for up to 72 hours after birth. In 2011, the same conditions were still in practise, but the average stay for women with normal birth had decreased to 2 days. In 1993 and 2011, parents and their newborn were invited to return to the maternity reception about 2–3 days after birth and to postnatal care 6–12 weeks after birth. There, they met a midwife who had experience in both postnatal care and breastfeeding. In addition, parents had regular contact with a nurse in child healthcare. Based on the “Ten Steps to Successful Breastfeeding” [1,2], early initiation of breastfeeding is important, as it is associated with longterm breastfeeding [4,5]. Other factors which influence breastfeeding positively include: skin-to-skin contact [6], continuity of care [7], support from partner, family and health professionals [8–11], being exclusively breastfed in hospital [12,13] and breastfeeding on demand [14]. Additionally, rooming-in is recommended as it promotes mother–child interaction and the likelihood of long-term breastfeeding [15,16]. Since the BFHI was introduced worldwide, several studies have evaluated its impact on breastfeeding rates from a healthcare perspective [17,18]. However, as far as we know, evaluation of the mothers’ perspective of the breastfeeding initiation is limited. Therefore, the aim of this study was to examine mothers’ experiences and feelings related to breastfeeding initiation from a two-decade perspective. Specific research questions were: Are there any differences in mothers’ experiences of breastfeeding when comparing results from 1992, 1993 and 2011? Are there any differences in mothers’ feelings about breastfeeding when comparing results from 1992, 1993 and 2011?
questionnaire at the maternity ward the day after the birth. The completed questionnaire was returned in an enclosed envelope when they left the maternity ward. A questionnaire was developed based on “Ten Steps to Successful Breastfeeding.” The questionnaire was constructed to evaluate the BFHI at the hospital. Results from the questionnaires that were collected in 1992 and 1993 have not been published until now. In the 2011 version, a group of staff members involved in providing breastfeeding support affirmed the content validity. They evaluated which questions were still relevant. A pilot study was performed among 16 mothers at a maternity ward in order to achieve face validity. They were asked to assess the questionnaire and indicate if they had any difficulty in responding to the questionnaire or if there were any cases of ambiguity. This resulted in minor corrections. From the questionnaire, 32 items were presented in this study. They are grouped into four areas: 1) six questions relating to background characteristics; 2) five questions about the first suckling occasion at the delivery ward; 3) three questions about their experiences of breastfeeding during their first day at the maternity ward; 4) mothers’ feelings related to the breastfeeding initiation were rated using the Alliance Scale [19] psychometric, which was tested in 2010. The scale had been used previously [20] but had not been tested for reliability and validity until 2010 [19]. At that point, it was named “Alliance Scale” due to its ability to rate mothers’ relation to their child and to the father. The scale takes only a few minutes to complete, which makes it easy to use. It has 18 items covering five dimensions concerning: mothers’ contact with child (four items), mothers’ contact with father (four items), mothers’ feelings towards breastfeeding, comfort (two items), mothers’ feelings towards breastfeeding, calm (five items) and mothers’ mood (three items) (Table 1). A semantic differential scale with response alternatives ranging from 1 to 7 was used with extreme expressions at each end; no figures were given. The endpoint sometimes represented a positive assessment and sometimes a negative assessment, thus, avoiding routine-like responses. Reliability coefficients were satisfactory (>.7) in all dimensions. Cronbach’s alpha was as follows: mothers’ contact with child was .79, mothers’ contact with father was .91, mothers’ feelings towards breastfeeding, comfort was .68, mothers feelings towards breastfeeding, calm was .87 and mothers’ mood was .83.
Methods A hospital in the south-east of Sweden was BFHI accredited in 1993. The hospital is an academic teaching hospital serving primarily middle class families. A repeated cross-sectional survey was conducted in 1992 and following the implementation of BFHI in 1993. In 2011, we repeated the survey once again. Participants Inclusion criteria for the study were: women with a normal vaginal birth, vacuum extraction for maternal indication and breech birth, having given birth to a full-term, healthy singleton infant, Apgar score of 9–10 after 5 minutes, good understanding of the Swedish language and being able to fill in a questionnaire. All women who fulfilled the inclusion criteria were invited to participate. In 1992, 83 women agreed to participate; in 1993, 74 women; and in 2011, 94 women. The women were recruited for 10 weeks in 2011. Response rates were 85.5% in 1992, 71.8% in 1993 and 89% in 2011. Study design and questionnaire The procedures for the surveys in all three studies were similar. All women received oral information about the study. Those women who gave informed consent were given written information and a
Table 1 Dimensions and included items. Contact with child Distant–Close Cold–Warm Insecure–Secure Difficult–Easy Contact with father Distant–Close Cold–Warm Insecure–Secure Difficult–Easy Mother’s feelings towards breastfeeding, calm Insecurity–Self-confidence Have to learn–Self-taught Difficult–Easy Tension–Relaxation Anxiety–Calm Mother’s feelings towards breastfeeding, comfort Constraint–Freedom Discomfort–Pleasure Mother’s mood Sad–Cheerful Unhappy–Happy Gloomy–Elated
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Table 2 Background factors of the participating women.
Age mean (SD)
Mothers 1992 (n = 83)
Mothers 1993 (n = 74)
Mothers 2011 (n = 94)
p-value
28.8 (SD 4.5)
27.5 (SD 4.9)
28.9 (SD5.3)
0.141
n (%) Education Primary school Secondary school College/university Parity Nulliparous Parous Born Sweden Other country Delivery Partus Normalis Breech Vacuum extraction Other Pain reliefa Epidural Nitrous oxide Acupuncture TNS Bath Pethidineb Other pain relief No pain relief Sex, child Male Female a b
n (%)
n (%) 0.000
9 (10.8) 48 (57.8) 22 (26.6)
13 (17.8) 47 (64.4) 13 (17.8)
5 (5.3) 36 (38.3) 53 (56.4)
34 (41.0) 49 (59.0)
28 (37.8) 46 (62.2)
49 (52.1) 45 (47.9)
81 (97.6) 1 (1.2)
73 (98.6) 1 (1.4)
88 (93.6) 6 (6.4)
77 (92.8) 1 (1.2) 4 (4.8) 0
73 (98.6) 0 (1.0) 0 (1.0) 1 (1.4)
92 (97.9) 0 2 (2.1) 0
15 (18.1) 47 (56.6) 0 0 0 10 (12.0) 16 (19.3) 24 (28.9)
10 (13.5) 55 (74.3) 0 2 (1.9) 0 10 (13.5) 34 (45.9) 13 (17.6)
33 (35.1) 85 (90.4) 23 (24.5) 5 (5.3) 37 (39.4) – 9 (9.6) 2 (2.1)
30 (36.1) 52 (62.7)
36 (48.6) 38 (51.4)
38 (40.4) 56 (59.6)
0.139
0.086
0.337
0.002 0.000 0.000 0.059 0.000 – 0.000 0.000 0.300
More than one option. Pethidine was not in use 2011.
The Regional Ethics Committee for Human Research, Faculty of Health Sciences, Linkoping University, Sweden, approved the study in 1991 (Dnr 92148). The Committee for Research Ethics in south-eastern Sweden approved the study in 2009 (Dnr EPK 372009).
Forsythe test was used. Data were entered and analysed with the IBM Statistical Package for Social Sciences SPSS 20.0. Findings Background factors
Analysis Differences between groups in categorical variables were tested by Kruskal–Wallis, and one-way analysis of variance (ANOVA) was used for others. Because of low internal dropout, missing values were excluded from the analyses. The endpoints of the semantic differential scale were recoded to obtain all the positive assessments at the higher endpoint. Cronbach’s alpha was used to assess internal consistency coefficients for the four dimensions of mothers’ feelings related to breastfeeding initiation (Table 1). Average scores for each dimension were calculated and differences between groups were tested by one-way ANOVA with Tukey’s post hoc test. In the event of statistically significant homogeneity of variance, the Brown–
As shown in Table 2, the three groups differed regarding education. There were twice as many mothers who had college/ university education in 2011 compared to the earlier years. The use of pain relief methods had also changed. The women used epidural, nitrous oxide and non-pharmacological pain relief methods to a higher extent in 2011. The use of Pethidine had ceased in 2011. Mothers’ experiences of their child’s first suckling and breastfeeding at maternity ward As shown in Table 3, the time before the baby sucked on the breast for the first time after birth was about 1 hour at all
Table 3 First suckling at delivery ward.
Time (minutes) between delivery and first suckling (mean, SD) Duration (minutes) of first suckling (mean, SD) Did the child attach to the nipple by him/herself? N(%) Yes No Did the child end the first suckling by him/herself? N(%) Yes No How do you estimate the child’s first suckling? N(%) Bad Both good and bad Good
Mothers 1992 (n = 83)
Mothers 1993 (n = 74)
Mothers 2011 (n = 94)
p-value
63.8 (91.7) 12.7 (12.1)
68.7 (119.5) 13.6 (13.1)
55.6 (87.1) 24.4 (21.0)
0.697 0.000 0.396
40 (50.0) 40 (50.0)
42 (58.3) 30 (41.7)
55 (59.8) 37 (40.2)
41 (52.6) 37 (47.4)
52 (70.3) 22 (29.7)
72 (78.3) 20 (21.7)
6 (7.4) 10 (12.3) 65 (80.3)
8 (11.0) 12 (16.4) 53 (72.6)
2 (2.2) 10 (10.8) 81 (87.0)
0.001
0.049
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Table 4 Differences in mean scores of mothers’ feelings towards breastfeeding initiation between the three groups (analysis of variance, ANOVA).
Contact with child Contact with father Feelings towards breastfeeding, calm Feelings towards breastfeeding, comfort Mood
Mothers 1992 (n = 83)
Mothers 1993 (n = 74)
Mothers 2011 (n = 94)
Mean (SD)
Mean (SD)
Mean (SD)
6.70 (0.5) 6.78 (0.5) 5.91 (1.0) 5.99 (1.0) 6.23 (1.0)
6.65 (0.7) 6.71 (0.9) 5.93 (1.0) 6.00 (1.2) 6.34 (0.9)
6.66 (0.5) 6.65 (0.8) 5.31 (1.3) 6.13 (1.0) 6.49 (0.9)
measurement occasions. However, the duration during the first nursing time varied; in 2011, the baby sucked almost twice as long compared with 1992 and 1993 (p < .000 and p < .000, respectively). The baby ended the first sucking on his/her own to a greater extent in 1993 and 2011 compared with 1992. The post hoc analysis showed a statistically significant difference between 1992 and 1993 (p = .047), and between 1992 and 2011 (p = .010). On the maternity ward, the women were asked to estimate the number of hours they had slept, the frequency of breastfeeding and the use of supplementation, formula or water during the first day, i.e. the day after birth. The results showed no differences in sleep duration for the 3 study years: 5.2 hours (SD 3.1) for 1992, 6.1 hours (SD 2.8) for 1993 and 5.4 hours (SD 2.6) for 2011 (p = .112). Regarding breastfeeding frequency per day, results showed a linear increase. On average, mothers breastfed 6.1 times (SD 2.2) in 1992, 7.1 times (SD 2.7) in 1993 and 8.0 times (SD 4.2) (p < .001) in 2011. Moreover, the post hoc analysis showed a statistically significant difference between 1992 and 2011 (p < .001). Results regarding supplementation indicated that the use of supplementation for the infants on the first day had changed. In 1992, 34.6% of the women reported supplementary use compared to 5.9% in 1993 and 9.3% in 2011 (p < .001). Mothers’ feelings related to the breastfeeding initiation Mothers rated their feelings towards breastfeeding using the Alliance scale. Their contacts with the child or the father did not differ during the years; neither did their mood. There were differences between the groups concerning the measure “mothers’ feelings . . . calm” as shown in Table 4. When comparing the separate items in the dimensions, mothers experienced breastfeeding as being more difficult (p < .001), and reported a higher degree of tension (p = .010), insecurity (p = .003) and anxiety (p < .001) in 2011 compared with 1992 and 1993 (Table 5).
p-value
0.856 0.501 0.000 0.672 0.191
Discussion The results indicate that over the study period, the mothers’ experiences related to breastfeeding initiations are partly consistent with BFHI. This leans towards increased respect for the recommendations given by the BFHI and the “Ten Steps to Successful Breastfeeding” [1,2]. One deviation is that supplementation is given to healthy newborn infants. Mothers also experienced breastfeeding as being more difficult and reported a higher degree of tension, insecurity and anxiety in 2011 compared with 1992 and 1993. When comparing labour ward routines, we found that the BFHI led to some important changes. In 1993 and 2011, the infant was placed skin-to-skin with his/her mother as soon as possible after birth. The first hours of skin-to-skin contact is of importance for the development of the child’s self-regulation and for maternal sensitivity [6]. When babies get to develop their rooting and tongue reflexes undisturbed, they learn to use them and do not need any help at the breast. Seminal works in this field [21,22] have shown that it takes approximately 50 minutes for the baby to find his/her way to the breast and start sucking if he/she lays naked on the mother’s breast directly after birth. The baby sucks for about 20 minutes if he/she gets to nurse freely [22]. The babies in the 2011 arm of our study came closest to the findings of these studies. Significant findings regarding labour ward routines indicate that during the two decades, the average duration of the first suckling was longer in 2011, namely, about 24 minutes. Another positive outcome in our study was that the infant stopped nursing by him/herself to a greater extent in 2011. These findings indicate that the labour ward routines take into consideration the inborn abilities of the infant and an understanding of the mothers’ need to learn to respond to this without undue interference. Although routines have changed over the years and midwives are more aware of the importance of the child’s first suckling, other factors may have influenced the routines. One such factor could be that the pain relief methods used have changed
Table 5 Differences in mean scores of mothers’ feelings towards breastfeeding between the three groups (analysis of variance, ANOVA).
Insecurity–Self-confidence Discomfort–Pleasure Constraint–Freedom Anxiety–Calm Tension–Relaxation Difficult–Easy Have to learn–Self-taught
Mothers 1992 (total n = 83)
Mothers 1993 (total n = 74)
Mothers 2011 (total n = 94)
Mean (SD)
Mean (SD)
Mean (SD)
6.06 (1.2) 6.30 (0.9) 5.69 (1.5) 6.33 (0.9) 6.22 (0.9) 5.94 (1.2) 5.06 (1.8)
5.97 (1.3) 6.24 (1.1) 5.75 (1.5) 6.37 (1.0) 6.24 (1.2) 5.94 (1.3) 5.19 (1.7)
5.39 (1.6) 6.40 (1.1) 5.86 (1.3) 5.72 (1.4) 5.76 (1.3) 5.08 (1.4) 4.59 (1.9)
p-value
0.003*,** 0.591 0.746 0.000*,** 0.010*,** 0.000** 0.088
Insecurity–Self-confidence 1992 and 2011 (p < 0.005), 1993 and 2011 (p < 0.023). Anxiety–Calm 1992 and 2011 (p < 0.002), 1993 and 2011 (p < 0.002). Tension–Relaxation 1992 and 2011 (p < 0.023), 1993 and 2011 (p < 0.24). Difficult–Easy 1992 and 2011 (p < 0.000), 1993 and 2011 (p < 0.000). * Brown Forsythe. ** Post hoc analysis: showed differences between.
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during the past two decades. For example, Pethidine is no longer used as a pain medication. When it was used, it affected the child’s alertness. Since 1996, in Sweden, epidurals have been used on a larger scale and on average, 50% of all primiparas had epidural anaesthesia during labour in 2011. It is shown that women who received epidural breastfed their children to a lesser extent during the first week after birth [23], and that infants whose mothers had received labour analgesia showed less alertness after birth [24]. The fact that the use of Pethidine has ceased cannot be the only explanation for the positive outcome of first suckling. Basically, the “Ten Steps to Successful Breastfeeding” [1,2] are still adhered to. However, step 6 concerning supplementation is still complicated. The maternity ward changed their practice and introduced rooming-in and breastfeeding on demand in 1993. A successful decline in the usage of formula was shown from 1992 to 1993; however, there was a tendency towards an increase in giving extra formula in our results from 2011. The amount or kind of supplementation could not be inferred from the study. Neither could medical indication. However, an increase in usage of formula is somewhat surprising given that only mothers who gave birth to a fullterm, healthy singleton infant were included in the study. When BFHI was introduced, health professionals were trained and breastfeeding discussions were in focus. Perhaps, breastfeeding has been taken for granted lately and the promotion of breastfeeding neglected. To be accredited or remain accredited as a BFH, it is not enough to just show high frequency of nursing; all ten steps need to be fulfilled. Our study demonstrates the need for evaluation of the BFHI as well as whether there is compliance with the recommendations. Continuous education and training of healthcare professionals is needed in order to gain an understanding of the importance of not giving supplements. In our study, mothers rated their feelings towards breastfeeding positively, but to a lower extent in 2011. The reasons why mothers’ feelings towards breastfeeding have changed are not investigated in this study; however, breastfeeding is affected by the mothers’ social situation, as well as their physical and psychological status [25–27]. The women in our study may also have been influenced by the equality debate that has been going on in Sweden over the past decade, where breastfeeding has been described in the media as being somewhat tedious, difficult and fraught with problems. In public places, lactating women have had to put up with being directed to remote rooms while breastfeeding. In social media, benefits of breastfeeding have been questioned and bottle-feeding has been portrayed as a choice one makes in an equal couple relationship. Whether or not breastfeeding continues or succeeds is also a result of health providers’ attitudes and approaches [11,13]. When breastfeeding is discussed in antenatal care and parenting groups, it is important to give a nuanced image of breastfeeding. If breastfeeding is described as a natural process that follows childbirth, mothers can perceive it as easy, which can invoke an unrealistic and idealised image [12]. At a time when mothers feel insecure and anxious about breastfeeding, the need for support must be addressed. In Sweden, most clinics have a written breastfeeding policy, which contributes to building consensus throughout the continuum of care. Midwives’ duties are to promote breastfeeding through the entire continuum of maternal healthcare, intrapartal care and postnatal care. Despite the existence of a breastfeeding policy, several changes have occurred during the last decade. The parent’s visits to antenatal care and parental classes have changed in both form and frequency, e.g. the number of visits to antenatal care has decreased for women with normal pregnancies. Similarly, many antenatal clinics only offer parental classes to primiparous women. This may have contributed to the fact that support for breastfeeding has diminished in relation to medical concerns. Another change is mother’s short length of stay at maternity wards. Nowadays, they stay only 1–2 days compared to previously
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when the mothers stayed until breastfeeding was established. The new parents have to gather a lot of knowledge and skills about breastfeeding during their short time at the maternity ward while at the same time going through an emotionally turbulent period. However, we are not suggesting an extension of the time spent at the maternity ward. Research [28] shows that early discharge is the best option for the mother and the baby. Nonetheless, when early discharge was introduced, the intention was to promote activities in order to support the woman and her partner. Specific follow-up is already established but may not be sufficient. Perhaps it is time to examine how the follow-up breastfeeding activities have functioned in this manner. Study limitations A limitation of the study is that the group of mothers studied in 2011 were different from those that gave birth 20 years ago. During this 20-year period, the level of education has increased. More women have college and university examinations. Studies [27,29] have demonstrated that higher education levels and older mothers are factors that influence breastfeeding positively. This cannot be related to the differences in the studies selection. The questionnaire is both a limitation and strength in this study. It was developed in 1991 and constructed based on the issues present during that time; however, major changes have taken place in maternity care since then. Today, many factors are obvious such as putting the baby to the breast after birth and rooming-in. On the other hand, using the same questionnaire allows us to make comparisons. Finally, the questionnaire has been tested psychometrically showing that reliability and content validity was satisfactory. Conclusion The mothers’ experiences related to breastfeeding initiations are partly consistent with recommendations given by the BFHI. The infant was placed skin-to-skin with his/her mother as soon as possible after birth and was breastfed freely. However, supplementation was given to healthy newborn infants, which does not conform to BFHIs intentions. Additionally, the mothers experienced breastfeeding as being more difficult and reported a higher degree of tension, insecurity and anxiety in 2011 compared with 1992 and 1993. Hospitals accredited as BFHI need to continuously evaluate their compliance with the standards. This would allow for an assessment of which routines need to be reviewed or revised. Conflict of interest No conflicts of interest have been declared. Acknowledgements The authors want to thank the participating women and Linda Lännqvist for data collection 2011. We are also grateful to Meena Strömqvist who revised the English. We acknowledge financial support from the Medical Research Council of Southeast Sweden. References [1] WHO/UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Geneva: World Health Organization; 1989. [2] Kyenkya-Isabirye M. UNICEF launches the Baby-Friendly Hospital Initiative. MCN Am J Matern Child Nurs 1992;17(4):177–9. [3] Socialstyrelsen. Amning och föräldrars rökvanor föräldrar födda 2011 [Breastfeeding and smoking habits among parents of infants born 2011]. Sweden: National Board of Health and Welfare; 2013. [4] Ekström A, Widström A, Nissen E. Duration of breastfeeding in Swedish primiparous and multiparous women. J Hum Lact 2003;19(2):172–8.
Please cite this article in press as: Karin S.M. Holmberg, Ulla M.C. Peterson, Marie G. Oscarsson, A two-decade perspective on mothers’ experiences and feelings related to breastfeeding initiation in Sweden, Sexual & Reproductive Healthcare (2014), doi: 10.1016/j.srhc.2014.04.001
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Please cite this article in press as: Karin S.M. Holmberg, Ulla M.C. Peterson, Marie G. Oscarsson, A two-decade perspective on mothers’ experiences and feelings related to breastfeeding initiation in Sweden, Sexual & Reproductive Healthcare (2014), doi: 10.1016/j.srhc.2014.04.001
