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International Journal of Nursing Practice 2014; ••: ••–••

RESEARCH PAPER

Multiparous mothers: Breastfeeding support provided by nurses Basak Demirtas RN MSc PhD Assistant Professor, Nursing Department, Faculty of Health Sciences, Ankara University Faculty, Ankara, Turkey

Accepted for publication March 2014 Demirtas B. International Journal of Nursing Practice 2014; ••: ••–•• Multiparous mothers: Breastfeeding support provided by nurses The study aimed to identify the informational, practical and emotional support that multiparous mothers had received from nurses in the early postpartum period.This is a descriptive and cross-sectional study on 278 multiparous mothers who took part in the research prior to their discharge from a maternity hospital in Ankara, Turkey. The instrument used was a 38-item questionnaire. Experiencing breastfeeding problems was the only statistically significant predictor of in-hospital supplementation (P < 0.01, OR 0.028, 95% CI 0.005–0.159). There were no statistically significant association between some predictor variables with regard to breastfeeding support and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems. No significant associations are indicative for the need of more effective implementation of informational, practical and emotional breastfeeding support for multiparous mothers in easing their adjustment to breastfeeding. Nurses can encourage multiparous mothers to maintain breastfeeding through individual teaching, giving mothers a sense of security, providing understanding care and telling about what to do with regard to breastfeeding problems. Antenatal education and support could be more likely to make a difference. Key words: breastfeeding support, breastfeeding, multiparous mothers, nurses, postpartum.

INTRODUCTION The United Nations International Children’s Emergency Fund recommends exclusive breastfeeding during the first 6 months of life, thereafter supplementing breast milk with solid and semi-solid foods for at least 2 years.1 However, breastfeeding initiation and exclusivity rates differ between and within countries, as well as social and cultural groups.2,3 It has been estimated that worldwide only 38% of infants are exclusively breast-fed for 6 months.4 The United Kingdom (UK) and the United States (US) have

Correspondence: Basak Demirtas, Nursing Department, Faculty of Health Sciences, Ankara University, 06340 Altındag˘, Ankara, Turkey. Email: [email protected] doi:10.1111/ijn.12353

some of the lowest rates of initiating breastfeeding and rates of breastfeeding duration among developed countries.5 The proportion of mothers who commence breastfeeding at birth is approximately 70%, but in the UK, by the end of the first week of the post-partum period, only 55% of mothers persist with breastfeeding. In the US, by 6 months of age, the percentage of infants breastfeeding dropped to 36, with 14% exclusively breastfeeding.5 In North America, breastfeeding rates are approximately 70% in regard to initiation. In Europe, initiation rates range from a low of 31–54% in Northern Ireland to 99% in Norway. South Asia (44%) and East Asia and Pacific (43%) are the regions with the highest levels of exclusive breastfeeding in the first 6 months of life, whereas Central and Eastern Europe and The Commonwealth of Independent States have the lowest levels (20%).6 © 2014 Wiley Publishing Asia Pty Ltd

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According to data from the ‘Turkey Demographic and Health Survey, 2008’, initiation rates within an hour and within 24 h after birth is 39% and 73.4%, respectively. The rate of exclusively breastfed babies under 6 months is 40%.7 Despite these rather low rates, the average duration of breastfeeding is 16 months in Turkey. The practice of introduce supplementary food early is widespread among infants.7 Early experiences such as availability of nurses, receiving practical support, encouragement and compassionate care in hospital are among the factors affecting the initiation and continuation of breastfeeding.8–11 Bystrova et al. found that ward routines/practices in both the labour and the maternity ward influenced milk production 4 days after birth.12 Similarly, Backström et al. found that the women felt safer when a health-care professional was present during a breastfeeding session.13 In many countries, the responsibility to support breastfeeding rests with midwives, not nurses.14,15 However, this is not the case in Turkey, and breastfeeding support is a significant component of nurses’ role.16–18 With nurses’ support, mothers can be empowered to feel confident, and perhaps some of the emotional distress associated with early motherhood can be avoided.19,20 Breastfeeding problems such as nipple pain/rash, insufficient milk supply, inverted nipple, problems with the baby failing to latch on properly could lead in-hospital formula supplementation in the early postpartum period.21–23 Conversely, in-hospital supplementation could lead breastfeeding problems.14,22 Informational, practical and emotional breastfeeding support can prevent breastfeeding problems and in-hospital formula supplementation.8,9,11 Murray et al. demonstrated that implementation of the five hospital practices supportive of breastfeeding such as breastfeeding within the first hour, breastmilk only, infant rooming-in, no pacifier use and receipt of a telephone number for use after discharge significantly increased breastfeeding duration rates.24 According to another study results, fewer than six prenatal visits, use of a pacifier within the first month and poor latch-on were among the factors associated with cessation of exclusive breastfeeding before 6 months.25 In their review, De Oliveira et al. identified that interventions spanning the prenatal period or both periods were generally more effective than interventions conducted only during the postnatal phase.26 In a study conducted by Maycock et al., the antenatal intervention and the additional resource materials distributed postnatally were found to significantly in© 2014 Wiley Publishing Asia Pty Ltd

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crease any breastfeeding at 6 weeks.27 Similarly, Simonetti et al. emphasized that breastfeeding promotion should start during pregnancy and continue both in the hospital and at home after discharge as the immediate postdischarge period is a very delicate psychophysiological moment of adaptation.28 Informational support defines providing information about benefits of colostrum, benefits of breastfeeding for mother and infant, properly latching on, breastfeeding positions, timing and frequency of breastfeeding, sufficiency of breastmilk, enhancing breast milk supply, breast care, cracked nipple care, and milk expression techniques.29,30 Practical support defines providing support practically to latch on properly, hold the baby, demonstrate breastfeeding positions and care for breast.19,31 Finally, emotional support defines providing understanding and compassionate care; providing individual care; giving encouragement; increasing mothers’ confidence; teaching what to do when they experienced a problem associated with breastfeeding; interacting with mothers; encouraging mothers to ask questions.32 There are a great deal of studies indicating that breastfeeding initiation rate in multiparous mothers is higher when compared with the primiparous mothers.22,33 Bystrova et al. demonstrated that milk production might be differently influenced in primi- and multipara women.12 Studies indicate that there is increased sensitivity of prolactin receptors in multiparous when compared with primiparous women.34 The first pregnancy induces permanent changes with regard to the release of oxytocin and oxytocin receptors.35 These changes resulting from maternal experience might facilitate the expression of oxytocinmediated functions, such as milk ejection, in connection with later pregnancies. Thus, early suckling might suffice to initiate milk production, when the mammary tissue is already primed. Despite this, the needs of multiparous mothers for support should not be neglected.22,33 There are studies stating that multiparous mothers complain of not being given explanations and helped because of their previous breastfeeding experiences.36,37 However, researchers suggest that all women should be encouraged to breastfeed immediately after birth.30,31,38,39 Research conducted to examine nurses’ support to multiparous mothers is sparse in Turkey. Objectives: 1. To identify the informational, practical and emotional support that multiparous mothers received from nurses in the early postpartum period.

Multiparous mothers

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2. To determine the association between some predictor variables such as receiving information, receiving practical support, interacting with nurses, asking question freely, receiving satisfying answer, and breastfeeding outcomes such as breastfeeding problems and in-hospital formula supplementation.

METHODS This descriptive and cross-sectional study was conducted at the post-partum ward in a ‘baby friendly’ maternity hospital in Ankara, Turkey.

Setting of the study The maternity hospital serves a socioeconomically diverse population and operates as both a community obstetrics service and a high-risk referral centre. The mother and newborn share the same room in the hospital. Formula and water supplementation for the infants in the hospital are forbidden unless medically indicated. If a mother–infant pair is in a good health, they are discharged from the hospital within 24 h after delivery. All mothers receive hospital maternity services regardless of how they are insured. If a mother is insured, the social security institution pays for the hospital expenditures. If a mother is not insured, she is benefitted from maternity insurance. Nurses hold the major responsibility for breastfeeding support. Mothers are encouraged to breastfeed within half an hour after giving birth. However, due to the small number of nurses, early hospital discharge and high staff workload, not all women are able to benefit from breastfeeding support. Breastfeeding training can be given by the nurses in the postpartum ward in the form of group training. The postpartum ward where this study was conducted is a busy one, where almost 15–20 mothers are discharged daily and three nurses work during the day time, and two on the night shift. There is a shortage of nurses in the ward. There are two separate postpartum wards in the hospital. The mothers who gave birth vaginally are admitted to one postpartum ward, whereas the mothers who gave birth by Caesarian section are admitted to the other ward. In the hospital, 9439 births took place in 2009.

Study sample Three hundred four mothers meeting the inclusion criteria were recruited (the total population who were

hospitalized in the postpartum ward between 1 June and 31 July 2010). Participants were recruited once they had been transferred to the postnatal ward. Twenty-six mothers were excluded from the study because 20 of them were separated from their infants as a result of respiratory problems, a cleft palate or early postpartum maternal complications such as maternal pain. Six out of these 26 mothers did not agree to participate in the study. Two hundred seventy-eight (91%) individuals were included in the study. The inclusion criteria for the study were having had an uncomplicated pregnancy and vaginal birth; infant birthweight of at least 2500 g; healthy, term infant; rooming-in with her infant during hospital stay; as well as breastfeeding initiation at the hospital.

Data collection A face-to-face structured interview lasted for half an hour with each mother, and was conducted by the researcher before discharge. Mothers, who were discharged every afternoon at about 1:30 pm, were asked to fill in the questionnaire. The 38-item questionnaire which consisted of open-ended and multiple-choice items was used to collect data. The questionnaire consisted of questions regarding demographics, pregnancy/birth characteristics, informational support, practical support and emotional support. Questions with regard to the demographics, pregnancy/birth characteristics, and some of the questions with regard to the informational, practical, emotional support were multiple-choice items. To ensure validity of the instrument, the advisory group included two nurses who are responsible for in-service training from the hospital, maternity nurse practitioners, a paediatric registered nurse and university faculty. All members of the advisory group have agreed on the questionnaire. Validity of the instrument was ensured through piloting the questionnaire successfully with 15 mothers. Their findings were not included in the final analysis. To ensure reliability of the instrument, the same advisory group examined the coding process of the answers given by the mothers for the open-ended questions. All members of the advisory group have agreed on the coding.

Statistical analysis The data from the questionnaire were entered into a computer database and analysed using SPSS 10.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis. Mean, standard deviation and percentages were used to analyse © 2014 Wiley Publishing Asia Pty Ltd

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the maternal characteristics. Percentage distributions were used to analyse the informational, practical and emotional support received by mothers. P values < 0.05 were accepted as statistically significant. Multiple logistic regression analyses were performed to evaluate risk factors for in-hospital formula supplementation. The dependent variable was in-hospital formula supplementation, and the independent variables could be characterized as maternal age and education, insurance, parity, pregnancy being planned/unplanned, breastfeeding initiation time, experiencing breastfeeding problem, receiving information, receiving practical support, asking question freely, availability of nurses and receiving satisfying answer. Because each of the said factors had been shown in previous studies to be important determinants for in-hospital formula supplementation,8,19,23 each was included in the full model used to evaluate risk factors. In addition to this, multiple logistic regression analyses were also performed to evaluate risk factors for experiencing breastfeeding problem. The dependent variable was experiencing breastfeeding problem and the independent variables could be characterized as mother’s age and education, insurance, parity, pregnancy being planned/unplanned, supplementary feeding, breastfeeding initiation time, receiving information, receiving practical support, asking question freely, availability of nurses, and receiving satisfying answer. Because each of the said factors had been shown in previous studies to be important determinants of experiencing breastfeeding problem,20,23,40 each was included in the full model used to evaluate risk factors.

Table 1 Participant characteristics Characteristic Maternal age (year) 17–25 26–34 35–41 Educational level Primary education and below† High school and above‡ Insurance Yes No Parity 2–3 4–5 Pregnancy being planned/unplanned Planned Unplanned Breastfeeding initiation time Within the first half hour Within 1–2 h Within 3–12 h Formula supplementation Yes No Total

Number (%)

Mean 28.08 ± 4.82

94 (33.8) 158 (56.8) 26 (9.4) 204 (73.4) 74 (26.6) 240 (86.3) 38 (13.7) 253 (91.0) 25 (9.0)

197 (70.9) 81 (29.1) 224 (80.6) 47 (16.9) 7 (2.5) 14 (5.0) 264 (95.0) 278 (100.0)

†

Includes illiterate, not completed primary education and completed 8-year primary education. ‡ Includes completed three-year high school education after primary school and completed university education.

Ethical considerations Authorization and ethical approval for the research were obtained from the General Directorate of the Curative Services of the Turkish Ministry of Health. This study was approved by the relevant ethics committee, and written informed consent was obtained from each participant. The participants received a verbal explanation of the content of the research.

RESULTS Participants As seen in Table 1, more than half of the women (56.8%) were between the age of 26–34 (mean age: 28.08 ± 4.82, min: 17, max: 41). There were 73.4% of the mothers who were graduates of primary school. Also, 70.9% of the mothers have had planned pregnancies. All mothers © 2014 Wiley Publishing Asia Pty Ltd

had initiated breastfeeding at the hospital. There were 80.6% of the mothers who initiated breastfeeding within half an hour. The percentage of the infants given formula was 5% (Table 1). Although not included in the table, over 97.5% were unemployed and majority have stated that they have middle-level income (78%). Additionally, insufficient milk (78.6%) and failing the baby to latch on properly (21.4%) were among the reasons for giving formula to their infants. All of the mothers were married and had experience of breastfeeding.

Associations between some variables and the breastfeeding outcomes Multiple logistic regression analyses were performed to evaluate risk factors for breastfeeding outcomes such as

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in-hospital formula supplementation and experiencing breastfeeding problem. The model to evaluate risk factors for in-hospital formula supplementation was a good fit (Hosmer–Lemeshow statistic, χ2 = 7.179, P = 0.517), and correctly predicted the outcome 96.0%. The relationship between variables and supplementation was explained as 40.5% (R2 = 0.405) (Table 2). The model to evaluate risk factors for experiencing breastfeeding

problem was a good fit (Hosmer–Lemeshow statistic, χ2 = 12.002, P = 0.151), and correctly predicted the outcome 81.3%. The relationship between variables and in-hospital breastfeeding problem was explained as 24.3% (R2 = 0.243) (Table 3). The most frequently cited breastfeeding problems that mothers experienced were nipple pain (60.3%), insufficient milk supply (28.6%), inverted nipple (19.0%) and

Table 2 Some variables and association with in-hospital supplementation of breastfed infants (n = 278) Variable

Mother’s age (years) 17–25 26–34 35–41 Mother’s education Primary education and below High school and above Parity 2–3 4–5 Pregnancy being planned/unplanned Planned Unplanned Breastfeeding initiation time Within the first half hour Within 1–2 h Within 3–12 h Breastfeeding problems Yes No Receiving information Yes No Receiving practical support Yes No Availability of nurses Available Unavailable Insurance Yes No Asking question freely Yes No Receiving satisfying answer Yes No

Number (%) n = 278

OR (95% CI) For supplementation

P

0.451 (0.045–4.472)

0.496

1.837 (0.416–8.109)

0.422

4.075 (0.333–49.883)

0.272

1.092 (0.238–5.010)

0.910

0.458 (0.013–16.713)

0.671

0.028 (0.005–0.159)

0.000

0.645 (0.115–3.618)

0.618

0.332 (0.079–1.393)

0.132

0.226 (0.034–1.496)

0.123

2.962 (0.609–14.408)

0.179

1.470 (0.192–11.269)

0.711

2.005 (0.261–15.379)

0.503

94 (33.8) 158 (56.8) 26 (9.4) 204 (73.4) 74 (26.6) 253 (91.0) 25 (9.0) 197 (70.9) 81 (29.1) 224 (80.6) 47 (16.9) 7 (2.5) 63 (22.7) 215 (77.3) 203 (73.0) 75 (27.0) 91 (32.7) 187 (67.3) 168 (60.4) 110 (39.6) 240 (86.3) 38 (13.7) 219 (78.8) 59 (21.2) 177 (63.7) 101 (36.3)

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Table 3 Some variables and association with in-hospital breastfeeding problem (n = 278) Variable

Mother’s age (years) 17–25 26–34 35–41 Mother’s education Primary education and below High school and above Parity 2–3 4–5 Pregnancy being planned/unplanned Planned Unplanned Breastfeeding initiation time Within the first half hour Within 1 to 2 h Within 3–12 h In–hospital supplementation Yes No Receiving information Yes No Receiving practical support Yes No Availability of nurses Available Unavailable Insurance Yes No Asking question freely Yes No Receiving satisfying answer Yes No

© 2014 Wiley Publishing Asia Pty Ltd

Number (%) n = 278

OR (95% CI) For breastfeeding problem

P

3.553 (1.068–11.822)

0.039

0.725 (0.329–1.595)

0.424

0.300 (0.080–1.119)

0.073

1.354 (0.658–2.783)

0.410

2.694 (0.381–19.044)

0.321

0.036 (0.007–0.176)

0.000

1.293 (0.611–2.738)

0.502

1.200 (0.557–2.588)

0.641

1.701 (0.837–3.456)

0.142

0.939 (0.373–2.362)

0.894

1.484 (0.579–3.807)

0.411

1.470 (0.600–3.597)

0.399

94 (33.8) 158 (56.8) 26 (9.4) 204 (73.4) 74 (26.6) 253 (91.0) 25 (9.0)

197 (70.9) 81 (29.1)

224 (80.6) 47 (16.9) 7 (2.5)

14 (5.0) 264 (95.0) 203 (73.0) 75 (27.0) 91 (32.7) 187(67.3) 168 (60.4) 110 (39.6) 240 (86.3) 38 (13.7) 219 (78.8) 59 (21.2) 177 (63.7) 101 (36.3)

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problems with the baby failing to latch on properly (15.9%) (Table 4). Experiencing breastfeeding problem was the only statistically significant predictor of in-hospital supplementation (P < 0.01, odds ratio (OR) 0.028, 95% confidence interval (CI) 0.005–0.159) (Table 2). Table 2 shows the ORs and 95% CIs for the variables in the complete model. There were no statistically significant association between predictors such as availability of nurses (P > 0.05, OR 0.226, 95% CI 0.034–1.496 and P > 0.05, OR 1.701, 95% CI 0.837– 3.456, respectively), asking question freely (P > 0.05, OR 1.470, 95% CI 0.192–11.269 and P > 0.05, OR 1.484, 95% CI 0.579–3.807, respectively), receiving satisfying answer (P > 0.05, OR 2.005, 95% CI 0.261– 15.379 and P > 0.05, OR 1.470, 95% CI 0.600–3.597, respectively) and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems.

Informational support received The most frequently cited pieces of information received by mothers on breastfeeding were the time and frequency of breastfeeding (80.2%), benefits of breastfeeding for mother and infant (78.8%), properly latching on (77.3%), and the benefits of colostrum for infant (75.9%). On the other hand, cracked nipple care (64.0%) was the least frequently cited pieces of information received on breastfeeding (Table 4). Only 69.5% of the mothers stated that the information they received was comprehensible. According to the findings, 73% of the mothers received informational support. Additionally, 50% of the participants who did not reach nurses stated that no explanation was provided as it was assumed their previous experiences supplied the necessary knowledge required (Table 4). There were no statistically significant association between receiving information and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems (P > 0.05, OR 0.645, 95% CI 0.115–3.618 and P > 0.05, OR 1.293, 95% CI 0.611– 2.738, respectively).

Practical support received Only 85.7% of the mothers stated that the practical support they received was beneficial, whereas more than half of the mothers (67.3%) did not receive any practical support (Table 4). The practical support that mothers received on breastfeeding was properly latching on

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Table 4 Informational, practical and emotional support received Number (%) Information on breastfeeding mothers received (n = 278)† Time and frequency of breastfeeding Benefits of breastfeeding for mother and infant Properly latching on Breastfeeding positions Benefits of colostrum for infant Crack nipple care Source of information (n = 278)‡ Nurse Did not receive any information Comprehensibility (n = 203)‡ Comprehensible Incomprehensible Practicability after discharge (n = 203)‡ Practicable Not practicable Practical support received (n = 278)† Properly latching on Holding the baby Breast care Breastfeeding positions Source of practical support (n = 278)‡ Did not receive any practical support Nurse Benefit of practical support (n = 91)‡ Beneficial Not beneficial Benefits (n = 78 )† Learned latching on/holding the baby Provided awareness of my mistakes Learned breastfeeding through practice Increased self-confidence Breastfeeding problems (n = 278)‡ Yes No Problems (n = 63)† Nipple pain/rash Insufficient milk supply Inverted nipple Problems with the baby failing to latch on properly Being understood (n = 63)‡ Feeling understood Not feeling understood Availability of nurses (n = 278)‡ Available Unavailable Types of unavailability (n = 110)† No explanation provided due to previous experience No effort made to solve problems No response received to questions posed Supportive behaviours (n = 278)† Encouragement Compassionate care Individual care Giving mothers a sense of security Telling about what to do regarding breastfeeding problems

223 (80.2) 219 (78.8) 215 (77.3) 212 (76.3) 211 (75.9) 178 (64.0) 203 (73.0) 75 (27.0) 141 (69.5) 62 (30.5) 137 (67.5) 66 (32.5) 94 (33.8) 91 (32.7) 89 (32.0) 87 (31.3) 187 (67.3) 91 (32.7) 78 (85.7) 13 (14.3) 45 (57.7) 44 (56.4) 33 (42.3) 19 (24.4) 63 (22.7) 215 (77.3) 38 (60.3) 18 (28.6) 12 (19.0) 10 (15.9) 37 (58.7) 26 (41.3) 168 (60.4) 110 (39.6) 55 (50) 40 (36.4) 37 (33.6) 189 (67.9) 126 (45.3) 85 (30.6) 71 (25.5) 53 (19.1)

†

More than one answer was given. The percentage calculations were made according to the ‘n’. ‡ The percentage calculations were made according to the ‘n’.

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(33.8%), holding the baby (32.7%) and breastfeeding positions (31.3%). The percentage of the mothers who stated that they learned about breastfeeding through practical support was 42.3%. Increasing self-confidence and providing awareness of their mistakes were also among the benefits of practical support they mentioned (Table 4). On the other hand, 80.6% of the mothers initiated breastfeeding within half an hour, whereas 16.9% initiated it within 1–2 h (Table 1). There were no statistically significant association between predictors such as receiving practical support (P > 0.05, OR 0.332, 95% CI 0.079–1.393 and P > 0.05, OR 1.200, 95% CI 0.557–2.588, respectively), breastfeeding initiation time (P > 0.05, OR 0.458, 95% CI 0.013–16.713 and P > 0.05, OR 2.694, 95% CI 0.381–19.044, respectively) and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems.

Emotional support received Encouraging (67.9%), providing understanding and compassionate care (45.3%), providing individual care (30.6%), increasing their confidence (25.5%), and teaching what to do when they experienced problems associated with breastfeeding (19.1%) were stated to be among the actions which encourage breastfeeding (Table 4). Approximately half of the mothers who experienced breastfeeding problems did not feel they were understood (41.3%). There were 39.6% of the mothers who could not interact with nurses. The most cited ‘types of unavailability’ of nurses were no explanation provided due to previous experience (50%), no effort made to solve their problems (36.4%) and lack of responses to women’s question (33.6%).

DISCUSSION The study examined the informational, practical and emotional support that multiparous mothers received from nurses in the early postpartum period. Multiparous mothers who had breastfeeding problems did not feel they were understood by nurses, most of the multiparous mothers did not receive any informational support and practical support such as properly latching on, holding the baby, breast care and breastfeeding positions because of their previous breastfeeding experience were among the key findings of this study. Despite the rate of multiparous mothers who received information seems rather high, interestingly there were no statistically significant © 2014 Wiley Publishing Asia Pty Ltd

association between receiving information and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems. Additionally, it was also determined that there were no statistically significant association between receiving practical and emotional support and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems. In this study, it was also determined that experiencing breastfeeding problem was the only statistically significant predictor of in-hospital supplementation. Conversely, it was also determined that supplementary feeding was statistically significant predictors of breastfeeding problem. Considering the findings of the study, it is not suprising that multiparous mothers mostly experience breastfeeding problems such as nipple pain/rash, insufficient milk supply and problems with the baby failing to latch on properly; and it is also not suprising that there is no statistically significant association between predictors such as receiving breastfeeding support and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems. In fact, it is expected that breastfeeding support can prevent breastfeeding problems and in-hospital formula supplementation.13,22,30 In the study hospital, no significant associations are indicative for the need of more effective implementation of informational, practical and emotional breastfeeding support for multiparous mothers in easing their adjustment to breastfeeding. The findings of this study identified that cracked nipple care was the least frequently cited pieces of information received on breastfeeding. However, the finding of this study demonstrates that one fourth of the multiparous mothers experience nipple problems. Research results have demonstrated that cessation of breastfeeding is associated with breastfeeding problems including the cracked nipple and nipple damage.8,19,21,40,41 Research by Sheehan et al. suggests that inadequate information on breastfeeding problems can have a negative effect on breastfeeding rates, contributing to the early cessation of breastfeeding.19 However, in this study, there were no statistically significant association between receiving information and breastfeeding problems. Research shows that effective implementation of breastfeeding support can prevent breastfeeding problems.23,33,42 In this study, no significant associations are indicative for the need of more effective implementation of informational support. In the study hospital, breastfeeding training can be given

Multiparous mothers

by the nurses in the form of group training. It is obvious that group training provided by nurses does not meet mothers’ needs. Lack of staff and workload might have decreased the efficiency of group training. Thus, it can be suggested that mothers who have breastfeeding problems could be given priority for breastfeeding support through individual teaching. According to the study findings, more than half of the multiparous mothers did not receive any practical support. It must be noted that the 80.6% of the initiation rate within half an hour indicate good breastfeeding outcomes. However, those mothers who did not initiate within half an hour could be supported to breastfed within half an hour with practical support. It is suggested that words alone offering support for breastfeeding were often inadequate, and women valued practical demonstrations and being shown how to feed their baby.14 It is expected that effective implementation of practical support can prevent breastfeeding problems and in-hospital formula supplementation.22,23,30 However, in this study, there were no statistically significant association between predictors such as receiving practical support, breastfeeding initiation time and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems. In this study, breastfeeding initiation rate among multiparous mothers is rather high. Despite this, they had breastfeeding problems and there were also no significant associations between receiving practical support and experiencing breastfeeding problem. This finding is worth being thought about. Because it demonstrates that even if there are high initiation rates, multiparous mothers need more effective strategies of practical support such as breastfeeding position and latching on. In the study hospital, the most important strategy to promote breastfeeding could be the effective implementation of early suckling. Practical support, such as direction in latching the infant on, is often viewed as crucial to reduce in-hospital supplementation.38,43,44 The intensity of breast engorgement was associated with milk production in primipara mothers, irrespective of labour ward routines, whereas multiparous mothers seemed to rely more on ‘sensory stimulation’, such as the procedure of early suckling or the routine of rooming-in.34 As a consequence, it might be easier to trigger milk production by sensory stimuli. Thus, early suckling and/or rooming-in might suffice to initiate milk production, when the mammary tissue is already primed.

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In the present study it was also determined that insufficient milk supply was among the most cited breastfeeding problems that multiparous mothers experienced. According to a study, mothers’ perception of insufficient milk at 4 weeks postpartum was significantly related to breastfeeding self-efficacy in hospital in the immediate postpartum period.45 Nurses in the study hospital could enhance breastfeeding self-efficacy in the immediate postpartum period through practical support to reduce maternal perceptions of insufficient milk and supplementation of breastfeeding. However, the hospital where this study was conducted is busy and there is a shortage of nurses compared with the number of patients. The usual postpartum stay is 24 h after normal vaginal delivery. Understandably, dealing with all of the mothers can be very difficult. Sheehan et al. concluded that breastfeeding experience requires support from skilful communicators with time to respond to a woman’s individual needs in a respectful and caring way.19 Backström et al. suggest that nurses can check back with the mother in 15–20 min, helping her to reposition the newborn on the second breast. Thus, if nurses cannot stay for the entire initial feeding, perhaps they could stay for the latch on and long enough to make sure the newborn is rhythmically sucking.13 In the study, the most cited ‘types of unavailability’ of nurses were no explanation provided due to previous experience, no effort made to solve their problems and lack of responses to their questions. The findings also demonstrated that approximately half of the multiparous mothers who experienced breastfeeding problems did not feel they were understood. Studies show that lack of availability, conflicting advice and unhelpful practices are important reasons when experiencing breastfeeding problem in the postpartum period and are associated with short duration of breastfeeding.19,20,23,33,36,41,46 Research shows that effective implementation of emotional support can prevent breastfeeding problems and in-hospital formula supplementation.13,23,30 However, in the present study, there were no statistically significant association between predictors such as availability of nurses, asking question freely, receiving satisfying answer and breastfeeding outcomes including in-hospital formula supplementation and breastfeeding problems. In this study, no significant associations are indicative for the need of improving more effective emotional support. Research shows that if mothers do not breastfeed or discontinue breastfeeding because of difficulties in initiating or © 2014 Wiley Publishing Asia Pty Ltd

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continuing breastfeeding, they might feel unsuccessful. Feelings of failure might, in turn, produce long-lasting emotional ill effects.43 It is therefore very important to improve emotional support. In this study, encouraging, providing understanding and compassionate care, providing individual care, increasing their confidence, and teaching what to do when they experienced problems associated with breastfeeding were stated to be among the actions which encourage breastfeeding. Satisfying multiparous mothers’ needs through verbal exchanges and empowerment programme could be effective to improve emotional support. Fenwick et al. found that the verbal exchanges that take place between a nurse and a mother influenced the woman’s confidence, her sense of control, and her feelings of connection between her and her baby.47 Empowerment programme could be an effective strategy to strengthening the desire of mothers to breastfeed, as well as helping them to acquire the appropriate skills and thereby enhancing their feelings of personal empowerment.48 However, the postpartum hospital stay is quite short. As long as there is no problem, the mother is discharged from the hospital 24 h after birth. As the period after birth is the time in which the mother adapts to the new condition, the education and consultancy services cannot be delivered sufficiently in this short period. In the circumstances, to compensate the disadvantages of the short hospital stay, it might be useful to improve antenatal care services. Antenatal education and support could be more likely to make a difference. In a study conducted to investigate Turkish women’s perceptions of antenatal education, all of the women who received group education emphasized their satisfaction with the group sessions.16 On the other hand, childbirth education classes might also be effective to implement empowerment programmes. Compared with other developed countries, the percentage of women receiving prenatal education in Turkey is low. As most women in Turkey deliver at hospitals, hospital-based prenatal breastfeeding education has the potential to access almost all pregnant women. Ustunsoz et al. emphasized that there is no standardized training provided to nurses to work in the prenatal field in Turkey at present, and they suggested that Turkish nurses and midwives who work in the prenatal area should receive specific standardized training to prepare them to present prenatal education.17 According to another study conducted in Turkey, it was found that attending childbirth © 2014 Wiley Publishing Asia Pty Ltd

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preparation class has a positive effect over breastfeeding.18 However, there are also study results that demonstrate prenatal educational programme including knowledge, affective and skill aspects did not show an effect on breastfeeding problem. In this case, the importance of programmes incorporating the component of consultation after delivery with prenatal education to help mothers conquer breastfeeding problems and increase the duration of breastfeeding was emphasized.49

STUDY LIMITATION Problems like pain, fatigue or hypovolaemia likely in the early postpartum period can also cause difficulties for the mothers during breastfeeding. Not using any assessment tools to evaluate the breastfeeding techniques of the mothers and making no observations in this area, using no scales to diagnose the breastfeeding problem, and determining the presence of the breastfeeding problem by depending on the answers to the questions only are the limitations of this study.

CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE In-hospital formula supplementation and breastfeeding problems multiparous mothers experienced such as nipple pain, insufficient milk supply and problems with the baby failing to latch on properly could be reduced by health professionals through implementing more effective informational, emotional and practical support. The findings have policy implications for strengthening the nursing profession, monitoring the quality of nurses’ breastfeeding support and improving the staffing levels of nurses. A more effective implementation of early suckling in a busy delivery ward environment and antenatal education and support could be more likely to make a difference.

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