Women´s experiences of initiation of breastfeeding on the labour ward
Introduction
This work will present a proposal for research looking at the issue of Irish women’s experiences of the initiation of breastfeeding on the labour ward. According to the National Perinatal Reporting System present in Ireland, it is known that, currently, only around 47% of Irish women initiate breastfeeding and it is hoped that this research can help to improve on this figure, given the health benefits, to mother and child, of breastfeeding. This research topic has been chosen as it is not a well researched area and the proposed research would, therefore, address a gap in the research.
Research question
The main research question that will be addressed in the proposed research is, “What are women’s experiences of the initiation of breastfeeding on the labour ward?”.
Research aims
The main aims of the proposed research are to undertake research to answer the research question that is proposed and to understand, through this, what measures might be taken to encourage a higher level of initiation of breastfeeding across women on the labour ward.
Research objectives
The main objectives of the research are, then, to:
1. Undertake a comprehensive literature review to understand what previous research has concluded about this issue
2. Undertake research to explore the proposed research question
3. As a result of the findings, make suggestions as to how to encourage a higher level of initiation of breastfeeding across women on the labour ward.
Literature review
Following searches of various online bibliographic databases including CinHal and PubMed, the literature review was compiled. The key terms and key words used for each search included ‘Breastfeeding inititation’, ‘Breastfeeding duration’ and ‘Breastfeeding Ireland’. Each of these key words and key terms were inputted in to the databases and the returns assessed manually for their relevance to the proposed literature review. The most relevant articles returned following this search form the basis of the literature review to be presented in this section.
Atchan (2011) discusses the fact that breastfeeding is the biological feeding norm for human babies, yet how many women choose not to breastfeed their newborn children, preferring, instead, to feed them with artificial baby milks which have demonstrated risks. As Atchan et al. (2011) discuss, around 10% of women on labour wards decide not to initiate breastfeeding, there being a variety of reasons for this. The first theme that will be addressed within the literature review is, therefore, what reasons are given for not initiating breastfeeding. This, obviously, forms part of the experience of women who initiate breastfeeding on labour wards, as the research in this area looks, specifically, at the decision-making process, and the experiences, of all women who think about initiating breastfeeding on the labour ward.
As Kong and Lee (2004) discuss in their research on the factors influencing the decision to breastfeed, international studies have consistently shown a low prevalence and short duration of breastfeeding in many women, with studies having identified several factors related to this low rate of initiation and short duration of breastfeeding. As Kong and Lee (2004) discuss, via a systematic literatura review format, these factors can be divided in to personal, social, cultural, facilities and environmental and other factors contributing to women’s decisions to breastfeed. Kong and Lee (2004) undertook research across 230 first-time mothers 24-48 hours after delivery of their child, using both quantitative and qualitative methodology to determine why the mothers decided not to initiate breastfeeding for their newborn child. This methodology is, therefore, sound, being based on a rigorous methodological approach. As Kong and Lee (2004) discuss, their results indicated that “…personal, cultural, social, and environmental factors are common influencing factors in the decision to breastfeed”.
It was found that the mother’s knowledge and attitudes, followed by husband’s support, were identified as most important in influencing infant feeding choice, with a confessed lack of knowledge of breastfeeding, on the part of the mother, being directly related to a failure to initiate breastfeeding. This research clearly shows, therefore, that a mother’s experience of initiating breastfeeding on the labour ward is influenced by a variety of factors, including personal, social, cultural and environmental factors. As the research showed, women’s experiences of initiating breastfeeding on a labour ward depends greatly on their own personal beliefs regarding breastfeeding and on their feelings whilst in the labour ward. It could be that a women wants to breastfeed, prior to entering the labour ward but, whilst in the labour ward, the environment is not conducive to them starting to breastfeed. Their experience of initiating breastfeeding would, in this case, be negative, not in line with their previous desires, simply as a function of the conditions they met whilst in the labour ward. It is clear, then, that in order to know the experiences of women regarding the initiation of breastfeeding on the labour ward, it is necessary to know what factors influenced the women’s decision to begin breastfeeding in the labour ward.
The next theme that will be explored in the literature review is the issue of what social factors affect a women’s decision to initiate breastfeeding and how this influences women’s experiences of initiating breastfeeding on the labour ward. Dubois and Girard (2003) discuss how guidelines, from the World Health Organisation, for example, recommend that newborns should be fed exclusively with breast milk during their first 4 to 6 months of life, yet many mothers do not initiate breastfeeding and do not continue breastfeeding, if initiated, up to the recommended time period. This is directly attributable, in many cases, to women’s experiences of initiating breastfedding on the labour ward, in that their experiences of this were negative and that this affected, directly, their ability to initiate breastfeeding in this setting. Dubois and Girard (2003), therefore, aimed to identify the main social determinants of initiation, duration and exclusivity of breastfeeding from birth to 4 months, at the population level. In order to explore this issue, the study utilised data from the Longitudinal Study of Child Development in Quebec (ELDEQ 1998-2002), analysing social data from all the children born in the province of Quebec in 1998, a total of 2223 children (Dubois and Girard, 2003). This methodology was assessed to be sound, given its reliance on the rigorous longtitudinal study, meaning that the results are likely to be reliable. It was found, following multivariate analyses of this social data and the initation status of breastfeeding and the duration of breastfeeding, that there were distinct relationships between the mothers’ education level, the annual family income, family type, the parents’ working situation and the mothers’ age group (Dubois and Girard, 2003). Women’s experiences of initiating breastfeeding whilst in the clinic were found to directly influence the later breastfeeding patterns found amongst the women in the sample.
The study, similar to results reported by Ingram et al. (2010), showed that when they reached 4 months of age, only 6% of the children were still being breastfed, with mother’s educational level being the greatest influential factor responsible for determining whether breastfeeding was initiated and, if so, how long breastfeeding continued for (Dubois and Girard, 2003). Women’s experiences of initiating breastfeeding on labour wards are, therefore, affected, directly, by women’s educational level. As Dubois and Girard (2003) state, “When all the studied factors are considered equal for all children, being breastfed in accordance with public health recommendations, which refers to exclusive breasfeeding for at least 4 months, is mainly influenced by mothers’ age, followed by mothers’ education level”. In conclusion, then, Dubois and Girard (2003) highlight the fact that once the decision to breastfeed is made, which is influenced mainly by the mother’s educational level, different factors affect the duration of breastfeeding. What the study made clear is that a variety of factors influence mother’s experiences of initiating breastfeeding on the labour ward. As such, the researchers recommended that it is important to educate mothers as to the importance of initiating breastfeeding and exclusively breastfeeding for at least six months (Dubois and Girard, 2003). Through education, it is hoped that even negative experiences of initiating breastfeeding on the labour ward can be ‘seen past’, allowing women to continue to breastfeed their child despite these negative experiences.
Aurora et al. (2000) undertook research to determine the factors influencing feeding decisions, breastfeeding and/or bottle initiation rates, as well as breastfeeding duration. The research was conducted on 245 mothers using a survey containing 28 simple questions, the survey aiming to assess various factors including: 1) demographics, 2) prenatal and postnatal care, 3) sources of breastfeeding information, 4) timing of decision, 5) preference, 6) type of feeding selected, 7) duration of breastfeeding, 8) factors influencing decisions to breastfeed and/or to bottle-feed, and 9) factors that would have encouraged bottle-feeding mothers to breastfeed (Aurora et al., 2000). As such, the survey was based on a very rigorous methodology which allowed the results obtained to be reliable in terms of providing insight in to the factors that affect women’s experiences of initiating breastfeeding on maternity wards. The study found that the breastfeeding initiation rate was 44.3% across the 245 mothers surveyed but that by the time the child was 6 months old, only 13% of mothers were still breastfeeding (Aurora et al., 2000).
The survey revealed that the most common reasons bottle-feeding was chosen included: 1) mother’s perception of father’s attitude, 2) uncertainty regarding the quantity of breast milk, and 3) return to work (Aurora et al., 2000). It was found that various factors would have encouraged mothers to initiate breastfeeding and to continue breastfeeding for longer, including: 1) more information in prenatal class; 2) more information from TV, magazines, and books; and 3) family support (Aurora et al., 2000). The study found, therefore, that there are many factors that affect women’s experiences of initiating breastfeeding on the labour ward: these factors including mother’s perceptions of their ability to breastfeed; mothers perceptions of their partners opinions towards breastfeeding; and mother’s perceptions of the health professionals caring for them whilst on the labour ward and the help and guidance provided by them, amongst other factors.
The research also found that there were various obstacles to breastfeeding, including the father’s attitude, the quantity of milk the mother perceived they were providing and time constraints, with the researchers suggesting that all of these are issues that can be discussed with mothers, on the labour ward, in an attempt to try to encourage greater duration of breastfeeding (Aurora et al., 2000). These factors were all found, for example, to be influential in determining mother’s experiences of initiating breastfeeding on the labour ward. In conclusion, then, Aurora et al. (2000), via the use of sound methodolgy and data analysis, recommended that “…extensive education regarding the benefits must be provided for both parents and optimally the grandmother by physicians, nurses, and the media before pregnancy or within the first trimester”.
Oyco-Santos (1983) undertook a study looking at the reasons behind mothers decisions not to initiate breastfeeding, surveyong 82 mothers. It was found that 73% of mothers intended, prior to giving birth, to breastfeed their child but that only 46% of mothers actually initiated breastfeeding once they had given birth. It was found, therefore, that many women’s negative experiences of initiating breastfeeding on the labour ward negatively influenced their decision to breastfeed and their ability to breastfeed their newborn child. As Oyco-Santos (1983) suggested, similarly to Kong and Lee (2004), then, there are various reasons why the desire to breastfeed does not convert in to actually initiating breastfeeding once the child is born, via the experiences that women have whilst initiating breastfeeding on the labour ward. These reasons, according to the research undertaken by Oyco-Santos (1983), include the mother’s age, with younger mothers failing to initiate breastfeeding at a much higher rate than oler mothers, and the educational level of mothers, with more highly educated mothers initiating breastfeeding at a higher rate than mothers without such a high level of education. Influences were also found for socioeconomic status and concerns about the effect of breastfeeding on the woman’s body, with the husbands opinión on this matter having a great influence on how the woman felt about this issue (Oyco-Santos, 1983). In conclusion, then, as with the findings of other researchers, such as Noble (2001), the researcher suggested that of all factors considered, past experience, of breastfeeding a previous baby, for example, and advice from close friends and relatives, were found to affect mothers’ decision positively (Oyco-Santos, 1983). Women who had access to these positive factors were found to be more likely to persist with breastfeeding on the labour ward despite negative experiences of initiating breastfeeding on the labour ward. These factors, therefore, acted as protective factors for initiating, and continuing with, breastfeeding. It was found that maternal employment, and the need to return back to work, was the most influential reason for deciding against breastfeeding (Oyco-Santos, 1983).
Noble (2001) examined whether planning to be employed postpartum has an effect on initiation of breastfeeding and the experiences of women who initiate breastfeeding on the labour ward. Using data collected from questionnaires of 8316 women who had given birth, a substantial sample size enabling the research to be rigorous, it was found that the decision to breastfeed was associated with any plans to work after having their child with those who planned to return to work within 6 weeks postpartum being less likely to initiate breastfeeding than those women who did not plan to return to work within the first six months of their child’s life, or later (Noble, 2001). This, directly, affected women’s experiences of initiating breastfeeding on the labour ward with women who planned to go back to work being less likely to have a positive experience of initiating breastfeeding in this setting. It was also found that “…older, more highly educated women, women who had or were planning to attend childbirth classes, women who were breastfed as infants, women who did not smoke and women who were giving birth to their first child were significantly more likely to initiate breastfeeding”, the study thus concluding that there are, therefore, certain demographic and social factors that influence, greatly, the decision to initiate, and to continue, breastfeeding. The study found, similar to the research by Ingram et al. (2010) and Kuan et al. (1999), that these factors influence, greatly, women’s experience of initiating breastfeeding on the labour ward: all of these factors have a say in whether women will have a positive, negative or neutral experience of initiating breastfeeding in this setting.
Ward et al. (2004), in a study based in Ireland, aimed to determine, “…the initiation rate, duration and exclusiveness of breastfeeding, in women resident in the North Eastern Health Board (NEHB) region”. An additional aim of the study was to identify the factors that influence the initiation and duration of breastfeeding, i.e., the experiences of mothers who were initiating breastfeeding on the labour ward, with 127 mothers being surveyed during the research. The research found that there are various attributes that are significantly associated with initiating breastfeeding, including, “…having previously breastfed, completed third level education, decision to breastfeed made early in pregnancy, being a non-smoker, having a mother who also breastfed, belonging to higher social class and age 24 years or older” (Ward et al., 2004). All of these factors, then, directly affect the experiences that women will have of initiating breastfeeding on the labour ward, with some of these factors being linked to successful initiation of breastfeeding and others being linked to a lack of success in initiating breastfeeding on the labour ward. After controlling for all of these variables in a regression model, however, it was found that only a few of these factors remained significant, namely, “…having previously breastfed, completed third level education and the decision to breastfeed made early in pregnancy” (Ward et al., 2004). For example, it was found that mothers who had made the decision to breastfeed early in pregnancy were more likely to have a positive experience of initiating breastfeeding on the labour ward. Conversely, those women who were not fully committed to breastfeeding their child were likely to have a negative or neutral experience of initiating breastfeeding on the labour ward. As Ward et al. (2004) conclude, then, similarly to the findings of Noble (2001), decisions on infant feeding method are often made prior to or early in pregnancy, this directly affecting the experiences that women will have of initiating breastfeeding on the labour ward, this meaning that efforts to increase breastfeeding rates will have to occur at societal level. The results suggested, therefore, that health sector initiatives can only have a limited effect in influencing the decision to initiate breastfeeding, meaning that “…creative methods must be developed and employed to encourage women from lower socio-economic groups to breastfeed” (Ward et al., 2004).
Brown et al. (2011) provide details of a study “…comparing healthcare professionals’ and mothers’ perceptions of factors that influence the decision to breastfeed or formula feed an infant”. This study follows on from that of Brodribb et al. (2007). As Brown et al. (2011) discuss, the World Health Organisation recommends that mothers should breastfeed exclusively for the first 6 months of age and then continue to do so alongside complementary foods for the first 2 years and beyond yet, despite these recommendations, the rates of initiation of breastfeeding are low and the duration of breastfeeding is suboptimal. As such, then, Brown et al. (2011) explored how healthcare professionals promote breastfeeding and how new mothers relate to this whilst on the labour ward, this affecting their experiences of initiating breastfeeding in this setting. It was found that professionals, “…described a range of influences on maternal decisions to breastfeed or formula feed including lack of knowledge, support and help with difficulties” and it was also found that these were, “…strongly echoed in the reasons mothers gave for formula use, suggesting clear professional understanding of the challenges relating to breastfeeding” (Brown et al., 2011). It is clear, from these results, then, that women’s experiences of initiating breastfeeding on the labour ward are not only influenced by demographic, personal and social factors, but, also, by the women’s experiences of healthcare professionals, the advice they give out and the attitude they have towards mothers in this setting. Women’s experiences of initiating breastfeeding are, therefore, affected by many factors, both internal to the mothers and external to them. Brown et al. (2011) concluded, following this study, that “…further resources and recognition are needed for healthcare professionals working with new mothers to enable them to offer increased support, with the aim of increasing breastfeeding duration”. This was suggested as a way of improving women’s experience of initiating breastfeeding on labour wards. It was suggested that, without this support, breastfeeding initiation would not be increased and, concomitantly, neither would the duration of breastfeeding.
The next theme that will be looked at is whether the hospital environment, or other interventions, can influence the mothers decision to initiate breastfeeding and the mothers experience of initiating breastfeeding on the labour ward. As Forster and McLachlan (2007) discuss, a number of practices during the intrapartum and very early postnatal period may affect breastfeeding initiation and the experiences of mothers during this period. As Forster and McLachlan (2007) discuss, all women “…should be encouraged to breastfeed soon after birth, with extra attention paid to the identification and offer of extra support for those women at higher risk of not successfully initiating and continuing breastfeeding”, yet this is often not realised in practice, especially if a woman decides not to make the choice to breastfeed and holds on to this idea very strongly. It is clear, from this research, then, that a variety of factors specific to the labour ward can affect the mothers experience of initiating breastfeeding.
As the research undertaken by Forster and McLachlan (2007) found, various factors affect breastfeeding initiation, including “…the implementation of the Baby-Friendly Hospital Initiative Ten Steps to Successful Breastfeeding at a service level; avoidance of the use of intramuscular narcotic analgesia, particularly near the end of the first stage of labour; not separating mothers and babies after birth for routine procedures; and placing healthy newborns on their mothers’ chest/abdomen (skin-to-skin) routinely”. All of these factors were found to be closely linked to the generation of positive experiences of breastfeeding for mothers in the labour ward setting. Failing, therefore, to encourage any or all of these factors thus means that it is likely that breastfeeding will not be initiated and, if initiated, it will not continue for long, as a direct consequence of the mothers having poor experiences of initiating breastfeeding whilst on the labour ward. As Forster and McLachlan (2007) discuss, given the findings of the research, it is unlikely that single strategies, in isolation, will increase breastfeeding initiation as stand-alone measures.
DiGirolamo et al. (2008), in a study similar to that undertaken by Bartick et al. (2009), assessed the impact of “Baby-Friendly” hospital practices and other maternity-care practices experienced by mothers on breastfeeding duration. The study aimed to look at how these factors affect the experiences of mothers initiating breastfeeding on the labour ward. It was found, through the study, that various factors affect a mothers decision to breastfeed, and their experiences of initiating breastfeeding, including “…breastfeeding initiation within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, fostering breastfeeding support groups”. As such, then, it is clear that greater training and education on the part of the staff in labour wards, with regards to these issues, would result in a greater level of initiation, and duration, of breastfeeding, through the fact that these would encourage a more positive experience of initiating breastfeeding for mothers in this setting. The research conducted showed that, lamentably, only 8.1% of the mothers surveyed had experienced all 6 “Baby-Friendly” practices, with the practices found to be initiation within 1 hour of birth, giving only breast milk, and not using pacifiers (DiGirolamo et al., 2008). It was also found that “….bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding termination” (DiGirolamo et al., 2008). Again, these results show that many factors influence the experiences of mothers whilst initiating breastfeeding. The research showed that, “…compared with the mothers who experienced all 6 “Baby-Friendly” practices, mothers who experienced none were approximately 13 times more likely to stop breastfeeding early” (DiGirolamo et al., 2008). It is clear, then, that the practices adopted by healthcare professionals on the labour ward have direct influence on the decisions of mothers to initiate breastfeeding, via their experiences of initiating breastfeeding, and their ability to continue to breastfeed should they meet problems with their breastfeeding. As such, then, DiGirolamo et al., (2008) concluded that it is necessary to improve the breastfeeding friendliness of labour wards.
In summary, then, the literature review has looked at several themes, including what reasons are given for not initiating breastfeeding, as a result of the experiences of initiating breastfeeding on the labour ward; what social factors affect a women’s decision to initiate breastfeeding and how these affect the experiences of initiating breastfeeding on the labour ward; and whether the hospital environment, or other interventions, can influence the mothers decision to initiate breastfeeding and what influence these factors have on the experiences of initiating breastfeeding on the labour ward. With regards to the first theme, the literature review clearly showed that there are many reasons that mothers give for not initiating breastfeeding, including personal, social, cultural, facilities and environmental and other factors contributing to women’s decisions to breastfeed and their experiences of initiating breastfeeding on the labour ward (Kong and Lee, 2004); mother’s knowledge and attitudes, followed by husband’s support and a confessed lack of knowledge of breastfeeding, on the part of the mother, being directly related to a failure to initiate breastfeeding, via a negative experience of initiating breastfeeding on the labour ward(Kong and Lee, 2004). It was found, for the second theme, that many social factors affect a women’s decision to initiate breastfeeding, including distinct relationships between the mothers’ education level, the annual family income, family type, the parents’ working situation and the mothers’ age group, all of which affect the experiences women have, of initiating breastfeeding on the labour ward (Dubois and Girard, 2003).
Oyco-Santos (1983) found that several factors influence the decision of a mother to initiate breastfeeding, and the experiences of initiating breastfeeding on the labour ward, including the mother’s age, with younger mothers failing to initiate breastfeeding at a much higher rate than older mothers, and the educational level of mothers, with more highly educated mothers initiating breastfeeding at a higher rate than mothers without such a high level of education. Influences were also found for socioeconomic status and concerns about the effect of breastfeeding on the woman’s body, with the husbands opinion on this matter having a great influence on how the woman felt about this issue (Oyco-Santos, 1983). With regards to the third theme, the literature review showed that a number of practices during the intrapartum and very early postnatal period may affect breastfeeding initiation, via influencing the experiences of initiating breastfeeding on the labour ward (Forster and McLachlan, 2007). It was also found that various factors affect breastfeeding initiation, including “…the implementation of the Baby-Friendly Hospital Initiative Ten Steps to Successful Breastfeeding at a service level; avoidance of the use of intramuscular narcotic analgesia, particularly near the end of the first stage of labour; not separating mothers and babies after birth for routine procedures; and placing healthy newborns on their mothers’ chest/abdomen (skin-to-skin) routinely” (Forster and McLachlan, 2007). Failing, therefore, to encourage any or all of these factors, which leads to negative experiences of initiating breastfeeding on the labour ward, thus means that it is likely that breastfeeding will not be initiated and, if initiated, it will not continue for long (Forster and McLachlan, 2007).
The main findings from the literature review, therefore, are that there are many reasons given for not initiating breastfeeding, via their negative effects on the experiences women have of initiating breastfeeding on the labour ward; that many social factors affect a women’s decision to initiate breastfeeding and their experiences of initiating breastfeeding on the labour ward; and that, yes, the hospital environment, or other interventions, can influence the mothers decision to initiate breastfeeding, given the strong influence these factors have on women’s experiences of initiating breastfeeding on the labour ward.
Suggested methodology
Research approach
The suggested approach will be a qualitative approach (Creswell, 2006; Polit and Beck, 2003). This approach is used a great deal in nursing research, especially in relation to topics such as this where it is desirable to attain a great deal of narrative information from individuals in order to address the research question being asked. In this case, given the research question, “What are women’s experiences of the initiation of breastfeeding on the labour ward?”, it is particularly necessary to utilize a qualitative approach as this will allow the collection of a large amount of narrative data from a sample of women, throught this allowing the research question to be explored. The researcher does not feel that the addressing of this particular research question via a quantitative method would be as successful as utilizing the qualitative approach.
Research design
It is suggested that the most practical approach for data collection would be to utilize a questionnaire of mothers on a labour ward of mothers who have recently given birth (Patton, 2001). It is suggested that the questionnaire should be composed of various sections, covering the mothers – and their partners – opinions about breastfeeding prior to giving birth and also postpartum, anout their opinions of the information and advice given during their time on the labour ward and about their experiences of initiating breastfeeding and their ability to continue to breastfeed following their initiation of this on the ward. The survey would, therefore, be comprehensive in terms of gathering mothers and fathers – qualitative – opinions of breastfeeding and, also, the experiences of the mothers on the labour ward with regards to the health care professionals attitudes towards breastfeeding and the help they received from the health care professionals with regards to initiating breastfeeding. The survey would, therefore, aim to include all necessary questions to be able to make a comprehensive assessment of all the possible influential factors regarding the decision to initiate breastfeeding and the ability of the mother to continue breastfeeding whilst on the labour ward.
In terms of how the questionnaire would be developed, there is no standard questionnaire that could be used to address the particular aims of the research suggested in this proposal, i.e., to undertake research to answer the research question that is proposed and to understand, through this, what measures might be taken to encourage a higher level of initiation of breastfeeding across women on the labour ward. As such, it was decided that it would be necessary to develop a novel questionnaire that would be used, as explained above, to collect relevant data from the women selected for inclusion in the research. The questionnaire, as has been discussed above, was therefore developed with a view to the considerations in mind. Following the development of the questionnaire, it was decided that it would be necessary to test its validity (Creswell, 2006) by means of a pilot study. This pilot study was undertaken by administering the survey to 10 women, all of whom were asked, firstly, to complete the survey and, then, to give their opinions as to how transparent and easy to use the survey was. Following this process, it was necessary to change the wording of a few of the questions in the survey as feedback from the women piloted suggested that the survey questions were difficult to understand and, as such, they had become confused as to what was actually required of them with regards to their answers. Following this process, then, the final version of the questionnaire was ready to be utilised in the research.
Population
In terms of the population of women who would be sampled, it is intended that the research be conducted in Ireland, with the women being sampled from one hospital labour Ward. Selecting women from one labour ward, in this manner, would allow the qualitative data collected to be free of bias, for example, as in this manner the women sampled would all have the same nurses, and surroundings, meaning that this could be controlled for in the data obtained and the analysis of such.
Sample
In terms of the sample of women selected for the research, it was decided, on balance between the number of responses required for these to be statistically significant and the time limits placed on the research project, that 100 women should be surveyed. This number was decided upon because it is sufficiently large for the answers to attain some level of statistical significance and because it is sufficiently small to allow the researcher the necessary time to collect the data, to analyse the responses and to write the results section of the final dissertation. In terms of how the 100 women will be sampled, it was decided that the women would be selected all from one maternity ward in one hospital in Ireland. This was because, as the literature review showed, the maternity ward setting in which a mother gives birth can have a major effect on breastfeeding initiation and so, if the researcher were to sample women from different maternity wards, the different practices across these wards could, potentially, bias the results obtained. It was considered important, then, to consider women from only one maternity ward.
With regards to how these women will be selected, the women will be approached via local GPs and asked if, once they enter the maternity ward setting, they would be willing to take part in the research. Once a ‘yes’ answer is gained from the women, the women would be asked to sign a form that would detail that they understood the purpose of the research and, as such, are willing to take part in the research on the condition that their responses to the questionnaire are maintained anonymous and confidential. In this way, the researcher assured that the women were fully informed of the research that would be undertaken and the requirements of the women in regards to the research. Following this process, it is expected that the desired sample of 100 women might not be attained and, as such, it will be necessary to approach more than 100 women initially, in terms of allowing for the potential for women to choose not to participate in the research.
Inclusion criteria
The main inclusion criteria that will need to be adhered to include the fact that women should be primiparous; should be English speaking and preferably Irish; should have atended antenatal classes; and should have given birth in the selected labour ward within one month of the survey being undertaken.
Exclusion criteria
The main exclusion criteria are that the women should not have experienced multiple pregnancies and births; should not speak a language, as their first language, other than English; should not be of a nationality other than Irish; should not have given birth on a ward different to the one selected for the data collection.
Data collection
The main method of data collection to be utilized is a qualitative survey. It is suggested that the most practical approach for data collection would be to utilize a questionnaire of mothers on a labour ward of mothers who have recently given birth (Patton, 2001). It is suggested that the questionnaire should be composed of various sections, covering the mothers – and their partners – opinions about breastfeeding prior to giving birth and also postpartum, anout their opinions of the information and advice given during their time on the labour ward and about their experiences of initiating breastfeeding and their ability to continue to breastfeed following their initiation of this on the ward. The survey would, therefore, be comprehensive in terms of gathering mothers and fathers – qualitative – opinions of breastfeeding and, also, the experiences of the mothers on the labour ward with regards to the health care professionals attitudes towards breastfeeding and the help they received from the health care professionals with regards to initiating breastfeeding. The survey would, therefore, aim to include all necessary questions to be able to make a comprehensive assessment of all the possible influential factors regarding the decision to initiate breastfeeding and the ability of the mother to continue breastfeeding whilst on the labour ward.
Pilot study
Following the development of the questionnaire, it was decided that it would be necessary to test its validity (Creswell, 2006) by means of a pilot study. This pilot study was undertaken by administering the survey to 10 women, all of whom were asked, firstly, to complete the survey and, then, to give their opinions as to how transparent and easy to use the survey was. Following this process, it was necessary to change the wording of a few of the questions in the survey as feedback from the women piloted suggested that the survey questions were difficult to understand and, as such, they had become confused as to what was actually required of them with regards to their answers. Following this process, then, the final version of the questionnaire was ready to be utilized in the research.
Ethical considerations
Clearly it would be necessary to respect the autonomy of the mothers selected for surveying and, also, to respect their confidentiality. To this end, then, all mothers would be asked to voluntarily offer themselves for inclusión in the research, this being obtained by the signing of a form and the researcher ensuring that all information provided would be kep anonymous and confidential. Additionally, as anurse researcher, the issues of non maleficience, beneficience and justice would be born in mind at all times, the mothers being treated, firstly, as patients, and secondly as research subjects.
Data analysis
The data collected via the qualitative survey would first need to be transcribed and, once transcribed, the responses provided by the participants would be analyzed using narrative analysis to be able to identify common themes running through the qualitative responses provided by the participants. Once these common themes had been identified, thematic analysis would be used to identify, further, these common threads, which would then be used to produce the results section of the final dissertation. It is expected that several common themes will be found in response to the qualitative survey, with these being used to make concrete assertions about the experience of the initiation of breastfeeding on the labour ward.
Rigour of study
The researcher has, in the design of the methodology, considered all possible sources of bias – such as the bias that could be introduced by looking at women from different labour wards – and has attempted to limit the amount of bias in the data collected, by addressing these potential sources of bias. As such, then, it is suggested that, as far as is possible, the research design is such that bias has been minimized: overall, then, the results can be taken with a large degree of certainty that they are rigorous and, therefore, reliable.
Expected findings
With regards to the expected findings, it is expected that the research question, “What are women’s experiences of the initiation of breastfeeding on the labour ward?” would be explored and that, through this, a better understanding would be obtained of the experiences of Irish women of initiating breastfeeding on the labour ward, with a view to making suggestions as to how healthcare professionals on such wards could improve the chances of more women initiating breastfeeding and being able to breastfeed for longer. It is expected that the research, given its novel nature, would be worthy of publication in a relevant nuring journal and that the research would also be worthy of presentation at conferences.
Overview of the methodology
Overall, then, the suggested methodology allows the research objectives to be addressed, namely to: 1. Undertake a comprehensive literature review to understand what previous research has concluded about this issue; 2. Undertake research to explore the proposed research question; and 3. As a result of the findings, make suggestions as to how to encourage a higher level of initiation of breastfeeding across women on the labour ward. It is expected, then, that the research will be useful in terms of providing information as to what factors influence women’s decision to initiate breastfeeding and what their experiences of initiating breastfeeding, and breastfeeding, are on the chosen maternity ward.
Conclusions
This work has presented a proposal for research looking at the issue of Irish women’s experiences of the initiation of breastfeeding on the labour ward. This research topic has been chosen as it is not a well researched area and the proposed research would, therefore, address a gap in the research, this being suggested as an important and necessary piece of research that would add a great deal to the literature in this area with, also, the hope that the research findings could help to improve rates of initiation, and the duration, of breastfeeding in Irish women.
References
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