A meta-synthesis of women's perceptions and experiences of breastfeeding support.
BACKGROUND
Breastfeeding conveys significant health benefits to infants and mothers yet in many affluent nations breastfeeding rates continue to decline across the early months following birth. Both peer and professional support have been identified as important to the success of breastfeeding. What is not known are the key components or elements of support that are effective in increasing the duration of breastfeeding?


OBJECTIVE
The aim of this meta-synthesis was to examine women's perceptions and experiences of breastfeeding support, either professional or peer, in order to illuminate the components of support that they deem 'supportive'. A secondary aim was to describe any differences between components of Peer and Professional support.


METHODS
Both primiparous and multiparous women who initiated breastfeeding were included in the study. Studies that included a specific demographic sub-group, such as adolescents, were included. Studies focused on a specific clinical sub-group, such as women post-caesarean, were not included.
This meta-synthesis focused on maternal experiences of breastfeeding support. The meta-synthesis included both formal or 'created' peer and professional support for breastfeeding women but excluded studies of family or informal support for breastfeeding.
Primarily qualitative studies were included in the review. Studies such as large scale surveys were also included if they reported in sufficient detail the analysis of qualitative data gathered through open ended responses or included in depth interviews. Only studies published or available in English, in peer reviewed journals and undertaken between 1990 and December 2007 were included.


METHODS
Key data bases were searched. The following search terms were individually added to the main keyword - breastfeeding: qualitative research, breast feeding support, peer support, professional support, postnatal support, post-natal support, volunteer support, lay support, breastfeeding counsellors, lactation consultants, social support, health education, breastfeeding education and lactation. Delimiters applied were humans, English language and years 1990-2007.


METHODS
JBI-QARI (Qualitative Assessment and Review Instrument) was used to assess the quality of 38 articles selected for full review. Seven were excluded primarily because they included little qualitative data relevant to the review focus. The studies reviewed were generally of reasonable quality in terms of clarity, appropriate methodology, credibility and evidence cited to support the conclusions drawn. However, most included relatively limited discussion of theoretical or conceptual perspectives, discussion of relevant literature and reflection on the roles of the researchers.


METHODS
JBI-QARI was used to manage and appraise textual data, Meta-ethnographic methods were used to develop 'interpretive explanations and understanding of breastfeeding support. Each study was systematically reviewed, reading and re-reading papers to create a list of themes through 'reciprocal translation'. Both first order and second order constructs were used to create the themes and these were then synthesised into four interpretive categories.


RESULTS
The meta-synthesis resulted in four categories comprising a total of 20 themes. The synthesis indicates that support for breastfeeding occurs along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as ineffective or even discouraging and counter productive. Second, the synthesis identified a facilitative approach, versus a reductionist approach as contrasting styles of support women experienced as helpful or unhelpful.


CONCLUSIONS
The findings of this meta-synthesis emphasise the importance of person-centred communication skills and of relationships in supporting a woman to breastfeed. Authentic presence is best supported by building a trusting relationship, demonstrating empathy, listening and being responsive to a woman's needs. Organisational systems and services that facilitate continuity of care/r and time spent with the woman, for example continuity of midwifery care or peer support models, are more likely to facilitate an authentic presence. The findings suggest the need to increase opportunities to offer women across all social groups access to peer support.


CONCLUSIONS
The review indicates several changes in direction for practice to foster provision of support that women consider helpful and enabling, rather than disabling. These include service design that facilitates effective relationships to be established between supporters and the woman, including greater continuity of carer, Midwives need to work in service models that enable them to provide more individualised, rather than standard care and advice, to spend time and provide practical help to those women who need it. Antenatal education needs to be more learner-centred, using pedagogic models based on adult-learning principles, and should provide women with information that is realistic, detailed and positively encouraging. Midwifery education needs to integrate sufficient focus on developing midwives' communication and information giving skills. Schemes to offer peer support should be developed further, using a pro-active approach, including home visits and support groups.


CONCLUSIONS
Further research is warranted on schemes to develop peer models of support. Research is also needed to investigate in more depth the service models and conditions that are conducive to midwives' ability to offer effective support for breastfeeding.
1. Associate Professor (maternal and child health) School of Nursing and Midwifery, University of Western Sydney, Sydney, Australia 2. Research Midwife, Centre for Research in Midwifery and Childbirth, Thames Valley University, Paragon House, Boston Manor Road, Brentford, TW8 9GA, UK and Deputy Director, Thames Valley Centre for Evidence-Based Nursing & Midwifery. 3. Senior Lecturer, Faculty of Nursing and Health, Avondale College, NSW, Australia and Adjunct Research Fellow, School of Nursing and Midwifery, University of Western Sydney, Sydney, Australia. 4. Professor of Anthropology & Health, Centre for Research in Midwifery and Childbirth, Thames Valley University, London, UK and also visiting professor, NMAHP Research Unit, University of Stirling. 5. Professor of Maternal and Infant Health and Director of Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Public Health and Clinical Sciences, University of Central Lancashire, England, Adjunct Professor, University of Western Sydney.
Virginia
V
Schmied
Sarah
S
Beake
Athena
A
Sheehan
Christine
C
McCourt
Fiona
F
Dykes