Challenges in Sustaining Breastfeeding

Chapter 1: Introduction

Breastfeeding exclusively for the initial period of six months of age just after the birth is considered to be the essential objective of nutrition and health for the baby and belongs to the public health programme throughout the globe as per the World Health Organisation, 2007 (World Health Organization, 2007). In this regard, the nurses along with the lactation consultants are thoughtfully engaged to enhance the rate of breastfeeding among the women for at least a period of 6 months post partum (WHO, 2007). According to the past scientific evidence, a woman who resides at western countries in maximum proportion does not continue with the breastfeeding for the required duration of 6 months (Hauck, 2011). There are certain key terminologies that will be used in relation to this topic within the present assignment and these will be detailed here one by one. The key terms which are used in relation to breastfeeding are “Intention” that defines any plan of action that has been developed to accomplish a certain goal via certain instrumental actions. This particular term in relation to the breastfeeding denotes about the intention about the women and her intrinsic desire to breastfeed her newly born child (Meedya, 2010). Another important terminology is the “social support” which according to the conceptual definition of McGrath, (2000) is the perception of the individuals towards the encouraging conduct of others who are within the community network of the individual that will be ultimately offer immense advantages to that particular person. Now in relation to breastfeeding, the social support is the perceptive encouraging conduct the women will receive from her social and community network (Meedya, 2010).

It is important to note that there are certain modifiable factors which positively impacts upon the time span of breast feeding such as biophysical parameters, psychosocial parameters, interventional parameters and the socio-demographic parameters (Cox, 2015). Among these the factors which are strongly adjustable are the main focus of this assignment. In the United Kingdom, the Infant feeding survey was conducted for the last time in the year, 2010. The key data obtained from the survey are that 81% of the women initiated breast feeding (it was 76% in the year, 2005); women who conducted breastfeeding exclusively for up to six weeks was 24%, 17% in the Wales, in the Northern Ireland it is 13%. Those who continued breastfeeding for up to three months were 17% which was 13% in the year, 2005. Similarly, exclusive breastfeeding for about four months were observed among 12% of the women populace which was around 5% in the year, 2005; and ultimately for six months exclusive breastfeeding was observed among only 1% of the population as per the recommendation of World Health Organisation, 2007 (Infant feeding survey, 2010). However, it should be noted that there were improvements observed within the rates of breastfeeding from the year 2005 to 2010 which could be attributed to the initiative taken, i.e., the Baby Friendly Initiative (Infant feeding survey, 2010). Moreover, in this regard, it must be mentioned that the data provided by the survey conducted in Scotland on Mothers and Infant Nutrition Survey, in the year, 2018 stressed upon the significant improvement in the rate of breast feeding for the duration of six months from the margin of 32% in the year, 2010 to 43% in the year, 2017 (Campbell, 2018). The statistical reports highlighted about the positive significance of the strategy involved for feeding of infants throughout the nation along with the 100% support from the maternity and community services in the Scotland to accomplish the Baby Friendly accreditation (Campbell, 2018). As per the randomized control study conducted on the exclusive breastfeeding among women in Australia for the period of six months post partum three factors that positively influenced breastfeeding process were identified such as the strong intention of the woman to breastfeed; the origin is from Asian group of nations; and the matured age of the mothers. The correlation of breastfeeding with age was direct in nature, i.e., with increase in the age of mothers the rate also enhanced (Wen, 2009). It should be mentioned in brief there are few factors that negatively affect the process of exclusive breastfeeding among the women for the required duration of six months are the negative or no such desire of the concerned women to breastfeed their child, women who have a strong addiction towards smoking, i.e., 20 cigarettes per day prior to pregnancy, no education about childbirth and health of the child and mothers, mothers who are obese; mothers who suffers from post partum depression after six months from the birth, and also if the baby gets adjusted to the infant formula provided to them when they were in the hospital may not want to feed upon breast milk (Wen, 2009). Therefore, within the study the researchers also highlighted that interventional support should be given to those women who have an intrinsic desire to breastfeed but also at a risk of early discontinuation (Wen, 2009). It is evident that augmenting the tendency to breastfeed the child will have a profound positive impact upon the health of the mothers and their child (Hausman, 2014). It is already evident that breastfeeding offers a passive immunity to the children from their mothers through the immunoglobulins that passes through the breast milk and eventually diminishes the chances of infection of the ear, throat, common cold and other gut infections (Hausman, 2014). In this way it can cut the cost of health burden upon the NHS for up to £50 million every year (Infant feeding survey, 2010).

Therefore, the present assignment will detail and critically appraise about the modifiable factors that positively influence the exclusive process of breastfeeding for the long span duration of six months. The second part of the assignment will discuss about the methodology adopted for the search of the appropriate literature in relation to the focused research topic, i.e., the search strategy adopted and the selection process of the articles, and also about the critical appraisal of the articles chosen using the tool, Critical Appraisal Skills Programme. Further in the result or discussion section of the literature review, emerging three themes will be identified and analysed followed by a summary and key points based conclusion.

Chapter 2: Overview of Methodology and Findings

Aim of the study undertaken:

What modifiable factors positively influence exclusively breastfeeding for duration of 6 months?

The purpose of the literature review is to recognize the modifiable factors that can positively influence exclusively breastfeeding for the introductory period of six months. Though the decision of breastfeeding is considered to be a matter of choice among the women, clinical experts especially the American Academy of Pediatrics (AAP) along with American College of Obstetricians and Gynecologists potentially recommends breastfeeding for the initial six months instead of any infant formula, juice or water (Raju, 2014). However, the concept of breastfeeding is highly controversial in the United Kingdom, as women goes through trauma while going through the process of breastfeed and though after trying hard they do not get success (Pérez-Escamilla, 2019). Many parents have expressed the agony that they have felt as they could not perform the best for the healthy growth of their child. Therefore, it has been considered to be a public health matter where the accountability for the persisting problem should be shared by the Government, policy creators, the overall community network and the families (Pérez-Escamilla, 2019). Moreover, it should be mentioned that the Unicef, UK stresses upon the government of the UK to execute about four keys of actions to promote encouraging environment for the women populace to breastfeed (Boyer, 2011). Varied high ranking peer reviewed journal articles have been screened with the aid of comprehensive search strategy, and the systematic literature review approach has been executed (Yeung, 2015). The methodology Critical Appraisal Skills Programme (CASP) framework has been formulated by Dr. Amanda Burls in Oxford in the year, 1993 (Singh, 2013). This particular framework has helped in the critical appraisal and the screening of the appropriate literatures while literature searches procedure. There are certain steps that have been followed to conduct an appropriate systematic review:

Identification of appropriate research question

Screening of the appropriate works of literatures

Data extraction from the selected evidence

Summarising and reporting the findings of the investigations into emerging themes (Yeung, 2015).

The Search Strategy Employed:

The primary and the secondary investigations are screened in accordance to the better comprehension of the focal research topic. Therefore, a search strategy was employed to select the appropriate literatures from the electronic databases. Articles were screened from suitable electronic databases where high impact peer reviewed contents are available on the following related subjects such as PubMed, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, PsycINFO, Taylor, Medline, Karger, Plos-One and Francis Online. The medical subject heading (MESH) terminologies were used to search articles specifically in relation to the focus topic and the Grey literatures were identified from the scientific content containing databases such as Open Grey, GreyNet International, and Med Nar. The search was conducted by customizing the restriction to the time span up to the year, 2020 so that the most recent relevant updates on the scientific field can be obtained for the systematic literature review purpose. The search strategy also involved the “truncation strategy” to achieve the most relevant contents such as breastfeeding*, modifiable factors*, health of mother and child*, social support*, etc. Moreover, this particular approach has led to the achievement of large number of articles from several electronic databases. In addition to this, the use of Boolean operators were used to broad the search outcomes such as ‘AND’, ‘OR’ that would also help to narrow down the query items (Yeung, 2015).

Selection of articles:

The study selection was done in accordance to the formulated inclusion and exclusion criteria for the focused research topic. For the formulation of the inclusion criteria the topic of the article along with catch words or phrases known as keywords and the abstract specification are taken into consideration based on which the relevant selection of articles was done. For defining the exclusion criteria, the literatures that are actually not falling within the “scope” of the focused researched topic and also not in accordance with the set inclusion criteria are not taken into consideration (Yeung, 2015). Moreover, any literature which is not communicated in the language English will not be considered for the purpose of literature review. Therefore, all the literatures that had been screened for the theme interpretation of the investigations were determined as per the set inclusion and exclusion criteria. The study selection was done by setting restriction upon the time span for the past 10 years only to include the most recent scientific updates and the nation wise restriction was set for the Europe and the United States. However, full length papers of few articles could not be achieved even if the abstract matched with the criteria due to the registration service particulars of the University.

The pre determined inclusion and exclusion criteria for the present investigation:

The positivism research philosophy has been adopted for the analysis of the present study as it could offer more appropriateness for the interpretation of the research findings with the aid of obtained truths or facts from the evident scientific sources of literatures (Bunniss, 2010). This particular approach helps to build an analytical mindset for the proper interpretation of the past study findings in accordance to the focused research questions (Bunniss, 2010). For the literature review purpose a structured systematic methodology has been adopted and the critical appraisal of the selected articles was done with the CASP tool and documented within the CASP table (Refer Appendix, Matrix table). This particular tool was chosen as it could be utilized within a wide setting that also includes public health. There is a separate checklist available at the website (www.casp-uk.net) for each study designs containing 10 – 12 questions each to critically appraise Randomised Controlled Trials (RCT), Systematic Reviews, Case Control Studies, Cohort Studies, Economic Evaluations, Qualitative studies, Diagnostic Studies, and Clinical Prediction Rule. This tool analyses the validity and reliability of the scientific articles and guides the researchers to screen the best possible evidences (Singh, 2013). As the study was a literature based review therefore no such ethical consideration should be required, however all the authors details of the in text citations are acknowledged to avoid any copyright issues along with the declaration of any conflict of interest to prevent plagiarism (Wiles, 2012).

Chapter 3: Discussion of the Themes Arising from the Review

Breastfeeding is evident to be beneficial for the health of both mothers and their child. However, though it is widely known about the benefits of breastfeeding still the rate of exclusive breastfeeding for the initial period of 6 months has still not reached the desired level as required throughout the globe (Roig, 2010). In this regard, it should be mentioned that comprehension of the factors that influence the process of breastfeeding might encourage the phenomenon, health benefits of the child and their mothers, along with the social support for the noble intention (Thulier, 2009). Several pieces of scientific evidences have already revealed about certain factors that can influence the process of breastfeeding by the mothers such as the socio-demographic parameters such as age, knowledge, financial condition, parity, the occupational details, etc (Thulier, 2009; Roig, 2010; Emmanuel, 2015). Among the other related parameters such as antenatal attendance, number of pregnancies, the delivery type, past experience of breastfeeding, the support gained towards breastfeeding, the education about the significance of breastfeeding for the health benefits of the babies, the intrinsic feeding desire of the mother, and also the birth weight of the infants (Emmanuel, 2015). It has been also reported by the researchers that women gets encouraged to breastfeed their child when they are given a positive perception about the breastfeeding their child. As per the study findings of Black, et al, 2008 poor breastfeeding is the cause of mortality of around 1.4 million children and disability of nearly 44 million children throughout the globe. Following this it has been suggested by the UNICEF, 2013 that mothers should exclusively breastfeed their child for the initial period of six months post partum and after that it should be supplemented with the infant growth formula for the next 2 years for the optimum growth and development of the baby (Cleminson, 2015). Therefore, in the following assignment the literature review has been critically appraised into the following emerging themes. According to the study of Emmanuel, (2015), the intention of the mother and the perceived seriousness which in turn depends on the benefits and the barriers acts as significant determinants of any health behaviour within a particular community. Moreover, the potential parameters of the perception are in turn influenced by certain modifiable factors such as socio-demographic, inspiration, skills, past experience of breastfeeding and the culture of the individuals (Cleminson, 2015; Emmanuel, 2015).

Theme 1: Socio-Demographic Variables

As mentioned earlier the socio-demographic variables comprises of age, knowledge, financial condition, parity, the occupational details, etc. of an individual. The relationship in between the maternal age and the rate of breastfeeding varies according to several researchers as some reported direct relation while others reported no such significant association. Author Ogunlesi (2010) mentioned that there is no such association in between breastfeeding and the maternal age whereas the study findings of Bolton, et al, 2009 and Ukegbu, et al, 2010 highlighted that matured age of mother is significantly associated with exclusive breastfeeding and also for a prolonged duration. Therefore, it is indeed required that health workers should better promotional intervention strategies for breastfeeding depending on the age of mothers in their neighbourhood (Ukegbu, et al, 2010). The role of education is considered to be significant in case of exclusive breastfeeding by some researchers. The study findings of Aarti, 2009, Okeh, 2010, Ajibade, et al., 2013 highlighted that those mothers who have their education below the secondary level have failed to continue with exclusive breastfeeding for a long duration and have contributed towards the pre-lacteal feeding process. Similarly, the study findings of Uchendu, (2009), Qureshi, et al, 2011 also stated the same that poorly educated mothers are less likely to continue with exclusive breastfeeding for the required duration. The principle reason behind this phenomenon is that mothers who are highly educated they are aware of the health benefits of breastfeeding both for the mothers and their child when compared with poorly educated mothers who does not know the reason behind the breastfeeding for a prolonged duration and only considers it as a matter of tradition or culture (Emmanuel, 2015). Therefore, to raise the awareness among the women, several campaigns and advertisements have been promoted or encouraged in varied dialects about the significant health benefits of exclusive breastfeeding for the suggested period of 6 months for both the mother and the child (Emmanuel, 2015). With regard to the occupation of mothers, researchers have confirmed that breastfeeding shares a competitive aspect with the employment responsibility of the working mothers and few times it may even act as a barrier (Okeh, 2010; Raffle, et al, 2011). Women who are engaged with a high responsibility job demonstrate a negative impact upon the breastfeeding process, as they does not get the required time. Women who are going to work daily outside home showed diminished rate of exclusive breastfeeding for the suggested six months. It was recognised by de Jager, et al (2012) that women faces a huge challenge to return to work and sustain it after achieving motherhood and therefore, they take the help of infant feeding formula for the growth and development of their child. Tan, 2011 highlighted that women who are unemployed demonstrate exclusive breastfeeding for the recommended duration while women who holds any administrative position or engaged with any kind of manual jobs may undertake mixed feeding as the option. In this regard, it should be mentioned that worse support is still observed within any work setting towards breastfeeding a newly born child though there are recommended guidelines in support of that (Reilly, 2013). According to the guidelines of WHO, (2013) that working women should be offered with supportive environment to encourage breastfeeding after joining work setting from the maternal leave and that they should be allotted at least one hour of break to breastfeed their child or express breast milk (Bai, 2013). Another interesting feature to note down that the financial or economic condition is significantly associated with breastfeeding. Studies of Okeh, 2010, Ekanem, et al, 2012, Ajibade, et al, 2013 have highlighted that higher stature of economic condition is related to extremely low rate of exclusive breastfeeding and also for an overall very short span of time. This can be well related to the findings of the women who are doing a high paid and responsible job in the society and the duration and pressure of the job have a severe negative impact upon the breastfeeding process (Emmanuel, 2015). On the other hand few researchers have also stated that unemployed women or belonging to a lower stratum of the economic condition also negatively impacts exclusive process of breastfeeding and also demonstrates for a short duration of time which could result in the malnutrition of the newly born child as observed (Emmanuel, 2015). Among all the socio-demographic factors, the relationship status of the women also plays a significant role in the process of breastfeeding as the status of being married is an important determinant according to few investigations (Sika-Bright, 2010; Ajibade, et al, 2013). It was also stated that single mothers are reported to feed sub optimally their child (Kimani-murage, et al, 2011; Tampah-Naah, 2013). It was also reported within the study that the basic principle behind this diminished rate shown by the single mothers is due to the lack of the support from their life partners, and also due to the absence of confidence when compared with the married women (Ajibade, et al, 2013). The study also showed statistical validation with P value < 0.001 to demonstrate the correlation in between the marital status and exclusive breastfeeding for a prolonged duration of time. The last factor within the socio-demographic factors is the parity although it’s impact upon the breastfeeding or infant feeding is observed to be unconvincing. This is due to the fact that within some settings, the multi parity has demonstrated positive or sometimes negative influences upon the process of breastfeeding (Ukegbu, et al, 2010; Qureshi, et al, 2011; Ikefuna, et al, 2009). On the other hand the studies of Ogunlesi, 2010 and Sapna, 2009 did not demonstrate any advantageous justification for the process of breastfeeding among the women.

Theme 2: Biological and Psychosocial Factors:

Parental care is also being referred to as antenatal care and it is considered to be under the preventive healthcare strategies. According to the study findings of Sapna, 2009 proper level of counselling during the antenatal care demonstrates immense positive benefits towards breastfeeding and therefore the practice of antenatal attendance has been considered to be the strong determinant for the procedure of infant feeding (Agho, et al 2009; Ghwass, 2011). According to the study highlights of Ogunlesi, 2010 antenatal care helps to enhance the chances of early breastfeeding and it was also observed that those mothers who do not attend the antenatal care demonstrates worse introduction and continuation of the exclusive breastfeeding (Ogunlesi, 2010). The aspect of “maternal prenatal intention” towards the process of breastfeeding is considered to have a significant impact upon the breastfeeding process (ALSPAC study Team, 2003). With greater level of intention along with the self efficacy the probability of breastfeeding exclusively for the period of six months gets significantly enhanced (Wilhelm, et al, 2008). Therefore, it should be planned accordingly to guide every women for the purpose of breastfeeding to their child by educating them about the feeding practices of their babies (Emmanuel, 2015). Moreover, according to the reports of Wambach, (2009), those women who are encouraged to breastfeed from their close friends and their family reveals to breastfeed for a prolong duration of time. In this respect, it should be mentioned that the presence of mother in law within family enhances both the self efficacy and the long haul duration of breastfeeding for the new mothers (Ku, 2010), also support obtained from the life partners of the women also encourages them to breastfeed for long (Meedya, et al, 2010; Tan, 2011; Brown, et al, 2011). The role of grandmothers is also found to be very positive for breastfeeding the newly born child for a long duration of six months. In this respect, the role played by the health workers and the clinicians are considered to be extremely impactful for the initiation and the continuation of breastfeeding (Kerr, et al, 2008; Grassley, 2008). Though it is evident that post natal support helps to encourage breastfeeding and their duration, however, there are also evidences that the healthcare professionals sometimes might confuse their clients while explaining about breastfeeding and giving suggestions for the implementations of the process (Brown, et al, 2011; Lamontagne, 2008). It was also reported that if the health workers visits home following the five weeks after the birth it genuinely enhances the exclusive breastfeeding process among the mothers. This particular intervention was taken into consideration to offer help to those women who faces some kind physical problems while breastfeeding such as pain in the area of nipple that causes a short term problem, inadequate production of milk within the mammary glands, also there is a negative correlation in between the breastfeeding and the caesarean delivery of the child (Berens, 2015; Ahluwalia, 2012). However, all these factors negatively influences the breastfeeding process of women but women who are inherently positive thinkers and shows positive robust attitude towards motherhood considers all these issues to be absolutely normal and can easily overcome it. The positive thinking helps them to overcome all the perceived barriers and enjoy the phase of their motherhood (Berens, 2015; Ahluwalia, 2012). Another modifiable factor that plays a role in the breastfeeding process among the woman is the self efficacy which is the belief that one possess about their own ability to do anything. It must be mentioned that this particular factor is impacted by varied experiences such as the past encounters of the person, the performance level of the individual in the form of live, recording or printed version (also being referred to as vicarious experience) (Bilszta, 2010). There are other factors that also enhance the self efficacy of the mothers to breastfeed their child are the verbal assurance from any healthcare professionals, peer group support, encouragement from the family members or the carers, and any kind of physiological excitement state or affirmative state (Leahy‐Warren, 2012). The other factors such as the agony, anxiety, excessive stress negatively influences the self efficacy of any individual. In this regard, it must be mentioned that the past experience of breastfeeding a child is considered to be a potential determinant for the purpose of exclusive breastfeeding (Brodribb, et al 2008; Meedya, et al, 2010). Those women who do not have any prior experiences of breastfeeding necessitates extra support from their immediate surroundings to properly feed their child but it has been also observed when compared to those women who have past experiences possess strong intention to exclusively breastfeed their child for the required duration of six months (Raffle, et al, 2011). Moreover, the opinions and beliefs of the family members and the friends demonstrate a strong influence upon breastfeeding and the confidence level of the women also plays a pivotal role. It is seen that a women who are more confident can properly breastfeed their child with less chances of failure (Leahy‐Warren, 2012).

In this respect another situation should be mentioned that those mothers who have given birth to twins encounters more trouble for exclusive breastfeeding in comparison to mothers who have one child (Emmanuel, 2015). Scientific evidences have also revealed that in case of mothers of twins the most crucial problems are the inadequate production of milk and the common timing to feed both the child that eventually results in early abstinence from exclusive breastfeeding. However, the study also revealed that if these mothers are encouraged and offered with support so that they can handle these problems for the introductory period of 6 weeks then, the mothers continued their breastfeeding for the suggested time span (Emmanuel, 2015). The mode of delivery is also considered to be a critical factor for exclusive breastfeeding. It has been observed that mothers who have given birth to a child normally demonstrates less stressful experiences towards breastfeeding and are more positive towards it, while those mothers who have given birth via caesarean section reveals insufficient production of milk, and have a tendency to utilize the infant growth formula to adequately feed their child (Handayani, et al, 2012; Carlander, et al 2009). However, few authors also reported that the mode of delivery had no relation with exclusive breastfeeding process. Infants who are born with lesser birth weight than the normal demonstrate avoidance towards exclusive breastfeeding (Matias, et al., 2012). Therefore, to provide them with the adequate nutrition for their proper growth and development they are often supplemented with infant growth formula along with breastfeeding, thus exclusive breastfeeding is not practiced for them usually (Matias, et al., 2012).

Theme 3: Knowledge or Education about exclusive breastfeeding:

Educating about the health benefits of exclusive breastfeeding for the child and the mothers have been considered to be a significant positive factor that influences and encourages the practice among the mothers (Bevan, 2014). It is necessary that all the mothers should understand that their breast milk is the ideal nutrition for the healthy growth and development of their child. It has the accurate combination of proteins, lipid and vitamins (Bevan, 2014). Moreover, breast milk also contains immunoglobulins that offer the baby with immunity to fight against several bacterial and viral infections. The breast milk also diminishes the chances of asthma and any allergies happening to the baby and also exclusive breastfeeding for the period of six months without the supplementation of any formula eventually causes lesser infections of ear, respiratory passages and also prevents the episodes of diarrhoea (Armstrong, 2014). It is also established by some studies that breastfeeding has a direct association with the higher level of intelligence in the later phase of childhood (Quigley, 2012). Another essential feature is that breastfeed allows the child to gain the right weight instead of overweight and also according to the source of American Academy of Paediatrics breastfeeding a child diminishes the chances of SIDS (sudden infant death syndrome), diabetes as well as in particular few malignancies (Vennemann, 2009). It is considered to be also important for the mothers to know the benefits of breastfeeding which positively influences the process, that the practice helps to burn out the additional calories and helps them to reduce weight much faster (Bevan, 2014). Most importantly, breastfeeding results in the production of an important hormone oxytocin that causes the uterus to revert back to their original prior pregnancy size and also diminishes the uterine bleeding after parturition (Bevan, 2014). Few scientific evidences have also revealed that the act of breastfeeding reduces the chances of breast and ovarian malignancies among women along with osteoporosis (Armstrong, 2014). Several studies have analysed about the educational interventions that have a positive influence upon the exclusive breastfeeding, however it has been observed that educating at both prenatal and postnatal period is considered to be the most effective one (Jenik, 2009). Researchers also reported that the joint effort of group education, visit to the home by the health workers, as well as offering personalized sessions during the antenatal and the postnatal period enhances the duration of exclusive breastfeeding among the women and it is considered to be the best supportive strategy (Jenik, 2009). However, the author also detailed about few limitations within the study investigations that most of the scientific articles offered adequate details about the adopted interventional strategies to promote exclusive breastfeeding for the period of six months such as about the strategy employed during education, numbers of learning materials offered, the session duration, setting of the educating place and ultimately the experience and the qualifications of the educators (Bevan, 2014; Jenik, 2009; Armstrong, 2014).

Few studies have revealed that educational strategy about the act of breastfeeding enhances the self efficacy of the women, i.e., educating women via videos or pictures help them to encounter any problems while practicing the act of breastfeeding with statistical validation of (χ2 = 28.8, df = 1, P value of < 0.001) (Charoghchian Khorasani, 2017).

Summary:

Moreover, it can be summarised that there are multiple modifiable factors that can have a positive impact upon the exclusive breastfeeding process among the mothers. It is also evident that multi-oriented interventions are more impactful in comparison to any single factor for the initiation and the continuation of breastfeeding (Kaunonen, 2012). All these strategies are the appropriate education of the mothers and the family about the significance of breastfeeding, support and encouragement from family members and their friends, early contact of skin to skin, training of the health workers, policies to support and encourage breastfeeding within the work setting, raising awareness with campaigns and educational programmes and most importantly acknowledging the motherhood by offering paid maternity leaves (Emmanuel, 2015). The literature discussed about the varied modifiable factors like the self efficacy, positive intention of the mothers to breastfeed their children, strong support from their life partners, family members, and from their friends that can positively influence the act of exclusive breastfeeding. Within the socio-demographic factors, several parameters such as the age of the mother, their educational level, their occupational details, the work setting environment, and the financial position, all these factors cumulatively affects the exclusive breastfeeding act for the suggested duration by WHO, 2007 (Berens, 2015; Ahluwalia, 2012; Brown, et al, 2011; Lamontagne, 2008). Therefore, any interventional strategies should involve not only the women but also their partners and the surrounding community to enhance the rate of act among the mothers. The individual perception about the breastfeeding was observed to be influenced by the modifying variables such as cues to action, and the self efficiency. To make any breastfeeding encouragement programme successful the appropriate comprehension of these factors helps to make a positive influence on the act of exclusive breastfeeding. In this respect how the socio-demographic factors of the mothers also influences the practice have been discussed and analysed explicitly. The other factors in total the numerous births, antenatal attendance, prior experience of breastfeeding, nature of delivery, support towards breastfeeding, maternal prenatal intention towards feeding, understanding of individual’s feeding as babies, and birth weight of babies, all modulates the action by some way or the others. Though some of the factors could be modifiable to get the positive outcome still the stress is given by several researchers towards the positive frame of mind and the strong intention of mothers to exclusively breastfeed their child for the required duration. Few interventional studies have also reported that attending the breastfeeding class by both the parents as a couple unit demonstrates more commitment of the partners towards the act of breastfeeding and in this way the male partner also able to understand that how they could show supportive actions towards their partner during the time so that the stress level of the mothers could be reduced (Emmanuel, 2015). It is observed that women attending with partners show 74% of initiation for breastfeeding in comparison to 42% of the women who attended the class alone with a statistical validation of P value 0. 02. As discussed earlier also the grandparents also play a supportive role for enhancing the duration of breastfeeding as they share their stories of breastfeeding and how it positively influenced the health of the child (Infant feeding survey, 2010). Few researchers also reported that both the mothers and the grandmothers play a supportive role after the child birth and this can be considered as a helpful intervention to support the act of breastfeeding. However, the literatures on the support offered by the matured adults of the family towards breastfeeding are found to be constrained (Infant feeding survey, 2010). From the point of view of a nurse the initiatives should be focused to educate the women and her partner about the benefits so that the act gets encouraged by all the close family members, to help the women during the time of breastfeeding if she is facing any difficulties, to lower down her level of stress during the whole process. However, it has been also noticed that many of the educational strategies have highlighted about the exclusivity of the breastfeeding process but not that much stress was given upon the importance of the suggested duration. To improve the culture of breastfeeding in the UK based on the demographics of the population and the political condition, the supportive culture is considered to be the crucial factor for enhancing the practicing rate of the act among the population of women. According to UNICEF, the major initiatives that could improve the rate of breastfeeding among the European women are the face to face ongoing support from all the local and social services of the community. In this respect the initiative namely, the Baby Friendly Initiative offers the mothers with required help from the healthcare initiatives, to impart a holistic care approach along with the child rights for proper growth and development. To achieve the success the health professionals also need to raise the standards which would help them to screen the best members of the staffs, so that personalized care could be imparted to each and every child. It should be mentioned in this aspect that organization, UNICEF is working in collaboration with WHO to exclusively project this life saving role (Clark, 2011). They have claimed that they have the appropriate information, integrity, and the proper infrastructure to collaborate with the organization, NHS so that they can offer standard quality care to each and every child that would make a difference in their live throughout the UK. To comprehend in details that in what way the Baby Friendly initiatives can impact upon the set goals of the public health, the hypothesis of change document on About Baby Friendly page should be studied (World Health Organization, 2014).

Chapter 4: Conclusion

Breastfeeding exclusively for the initial period of six months of age just after the birth is considered to be under the public health programme throughout the globe as per the World Health Organisation, 2007. However, according to the past scientific evidence, a woman who resides at western countries in maximum proportion does not continue with the breastfeeding for the required duration of 6 months. In the United Kingdom, the Infant feeding survey was conducted and the key data obtained from the survey is exclusive breastfeeding was observed among only 1% of the women population for six months as per the recommendation of World Health Organisation, 2007. It is important to note that there are certain modifiable factors which positively impacts upon the time span of breast feeding such as biophysical parameters, psychosocial parameters, interventional parameters and the socio-demographic parameters. In this respect, as mentioned above exclusive breastfeeding among women in Australia for the period of six months post partum three factors that positively influenced breastfeeding process were identified such as the strong intention of the woman to breastfeed; the origin is from Asian group of nations; and the matured age of the mothers. In this regard, it should be mentioned that comprehension of the factors that influence the process of breastfeeding might encourage the phenomenon, health benefits of the child and their mothers, along with the social support for the gracious intention. The positivism research philosophy has been adopted for the analysis of the present study and a structured systematic methodology has been adopted and the critical appraisal of the selected articles was done with the CASP tool. Therefore, in the following assignment the literature review has been critically appraised into the following emerging themes. The maternal age and the rate of breastfeeding vary according to several researchers and some study reported that matured age of mother is significantly associated with exclusive breastfeeding and also for a prolonged duration. Those mothers who have their education below the secondary level have failed to continue with exclusive breastfeeding for a long duration and the principle reason behind this phenomenon is that mothers who are highly educated they are aware of the health benefits of breastfeeding both for the mothers and their child when compared with poorly educated mothers. With regard to the occupation of mothers, researchers have confirmed that breastfeeding shares a competitive aspect with the employment responsibility of the working mothers and few times it may even act as a barrier as women faces a huge challenge to return to work and sustain it after achieving motherhood and therefore, they take the help of infant feeding formula for the growth and development of their child. Antenatal care is considered to be under the preventive healthcare strategies and it demonstrates immense positive benefits towards breastfeeding and therefore the practice of antenatal attendance has been considered to be the strong determinant for the procedure of infant feeding. Moreover, with greater level of intention along with the self efficacy the probability of breastfeeding exclusively for the period of six months gets significantly enhanced. The opinions and beliefs of the family members and the friends demonstrate a strong influence upon breastfeeding and the confidence level of the women also plays a pivotal role. It is seen that a women who are more confident can properly breastfeed their child with less chances of failure. It is necessary that all the mothers should understand that their breast milk is the ideal nutrition for the healthy growth and development of their child. Exclusive breastfeeding offers the baby with immunity to fight against several bacterial and viral infections and also diminishes the chances of asthma and any allergies happening to the baby and results in the production of an important hormone oxytocin that causes the uterus to revert back to their original prior pregnancy size and also diminishes the uterine bleeding after parturition among the mothers. Therefore, to improve the culture of breastfeeding in the UK based on the demographics of the population and the political condition, the supportive culture is considered to be the crucial factor for enhancing the practicing rate of the act among the population of women.

There are few recommendations that could be made to improve the persisting situation, in terms of policy and campaigns, robust awareness campaigns about the health benefits of exclusive breastfeeding for both the mother and child should be made in several languages so that lower educational level women could also comprehend the information suspended. Antenatal care should be focusing upon solving the problems in relation with breastfeeding by the healthcare workers. The Government must ensure that working women should get the appropriate facilities to breastfeed their child for their healthy growth and development. For example maternity leave should be for six months strictly as it would ensure exclusive breastfeeding and support of families and life partners along with special support should be provided to those mothers who have given birth to twins and faces a challenging situation at the time of breastfeeding. Moreover, parents as a couple unit must demonstrates more commitment towards the act of breastfeeding and in this way the male partner might also able to understand that how they could show supportive actions towards their partner during the time so that the stress level of the mothers could be reduced. At last to achieve the success the health professionals also need to raise the standards which would help them to screen the best members of the staffs, so that personalized care could be imparted to each and every child.

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