Published online August 1, 2006
PEDIATRICS
Vol. 118
No. 2
August 2006, pp.
e309-e314
(doi:10.1542/peds.2005-2064)
A Mother's Feelings for Her Infant Are Strengthened by Excellent Breastfeeding Counseling and Continuity of Care
Anette Ekström, PhD, RNM and
Eva Nissen, PhD, RNMTD
School of Life Sciences, University of Skövde, Skövde Sweden; Department of Woman and Child Health, Division of Reproductive and Perinatal Health Care, Karolinska Institutet, Stockholm, Sweden
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ABSTRACT
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OBJECTIVE. Continuous support during the childbirth process ultimately may strengthen the mother's self-esteem and her capacity to interact with and nurture her infant and also may improve paternal involvement in general. In the present study, we investigated whether mothers, who were attended by midwives and nurses who had had a process-oriented training program in breastfeeding counseling, perceived stronger maternal feelings for their infant than mothers who had received only routine care.
METHODS. In a previous study, an intervention that included a process-oriented program on breastfeeding counseling for health professionals and continuity in family classes through childbirth was conducted. The 10 largest municipalities were classified in pairs that were similar in size and had similar figures of breastfeeding duration. The municipalities were randomized pairwise to either an intervention or a control group. The present study is a follow-up study on women's feelings for their infants in relation to the kind of care that they had had and was undertaken between April 2000 and January 2003. The sampling frame was based on women who were cared for at either the intervention clinic or control clinics. The mothers at the control clinics had received standard routine care and had attended family classes through the point of birth. Data collection for control group A started before effects of the intervention could be studied. Data for control group B were collected simultaneously with data collection for the intervention group (n = 540). The mothers responded to 3 questionnaires at 3 days and at 3 and 9 months postpartum. Background data of the mothers were collected. The perception of support that was provided by the health professionals and the perception of mother–infant relationship and feelings for the infant were rated on Likert scales.
RESULTS. At 3 days postpartum, both the intervention group and control group B versus the control group A thought that their understanding of the infant was better, they perceived more strongly that the infant as their own, and they enjoyed more breastfeeding and resting with the infant. Although there was no significant difference between the intervention group and control group B at 3 days and 3 months observation, mothers in the intervention group talked more to their infant, perceived their infant to be more beautiful than other infants, and perceived more strongly that the infant was their own than did the mothers in control group B at 9 months observation. In addition, the mothers in the intervention group felt significantly more confident with the infant and felt the infant to be closer than did the mothers in control group B.
CONCLUSION. A process-oriented breastfeeding training program for antenatal midwives and postnatal nurses that included an intervention that guaranteed continuity of care strengthened the maternal relationship with the infant and the feelings for the infant.
Key Words: breastfeeding support • WHO recommendations • health education • maternal feelings
Abbreviations: CGA—control group A • CGB—control group B • IG—intervention group
In a previous study, we found that a process-oriented training program in breastfeeding counseling for antenatal midwives and postnatal nurses combined with an intervention that guaranteed continuity of care made the mothers perceive more satisfaction with emotional and informative support that was provided by the antenatal midwives and the postnatal nurses during the first 9 months postpartum.1 Continuous support during the childbirth process ultimately may strengthen the mother's self-esteem and her capacity to interact with and nurture her infant and also may improve paternal involvement in general.2,3 The mechanism behind this may be that the nurse relieves the mothers from stress over her transition to parenthood and the anxiety that she feels about the well-being of the infant by active attentive listening and providing a calm and understanding atmosphere around the mother while helping her with the best advice to facilitate good breastfeeding.1 Continuous support therefore may lead not only to patient satisfaction but also to additional positive effects on her interaction with her newborn infant. In the present study, we therefore wanted to determine whether mothers who are attended by midwives and nurses who have had a process-oriented training program in breastfeeding counseling perceive stronger maternal feelings for their infant than mothers who have received only routine care.
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METHODS
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In Sweden, first-time gravidae together with their partners are offered family classes, which aim, among other things, to increase the knowledge about parenthood and forming a parental network. Family classes begin at the Antenatal Centre during the 25th week of pregnancy and are conducted by the midwife. Family classes are usually offered after childbirth but are then conducted by the postnatal nurse at the Child Health Centre. Standard routine care provides family classes that usually are discontinued at birth.4
Study Population
In a previous study, breastfeeding practices and duration of breastfeeding in relation to perceived support and information were surveyed in the southwest of Sweden.5,6 The results showed that counseling and support by health professionals needed to be improved. An intervention that included a process-oriented program on breastfeeding counseling for health professionals and continuity in family classes through childbirth was conducted from September 1999 to March 2000.7,8 The process-oriented training program included lectures on breastfeeding management and promotion. Altogether, the health professionals met at 7 sessions, and at each session, counseling skills and personal breastfeeding experience were reflected. The participants were encouraged to develop a common breastfeeding policy between the antenatal and receiving child health centers. The family classes also were kept together before and after childbirth. The antenatal and postnatal centers in the 10 largest municipalities were classified in pairs that were similar in size and had similar figures of breastfeeding duration. The municipalities were randomized pairwise to either an intervention or a control group.6,7
The present study is a follow-up study on women's feelings for their infants in relation to the kind of care that they had received, and the study was undertaken between April 2000 and January 2003. The sampling frame was based on women who were cared for at either the intervention clinic or control clinics. The mothers at the control clinics had received standard routine care and had attended family classes through the point of birth. Data collection for control group A (CGA) started before effects of the intervention could be studied. Data for control group B (CGB) were collected simultaneously with data collection for the intervention group (IG). The methodologic approach in this study, having 2 control groups (the first one before the intervention group and the other one collected simultaneously with the intervention group) was used to detect effects of the intervention.
Eligibility for this study was defined as Swedish-speaking mothers who gave birth to singleton, healthy, term infants who were delivered spontaneously, by vacuum extraction, or by cesarean section. Mothers who had given birth to infants with life-threatening diseases or malformations were excluded. All mothers who fulfilled the inclusion criteria were invited to participate in the study; in all, there were 584 mothers. Of those, 540 gave their informed consent to participate in the study.
Questionnaires
The longitudinal study was based on 3 questionnaires that were developed for the purpose of this study. The maternity staff distributed the first questionnaire to the participants when the infant was 3 days of age. Follow-up questionnaires were sent to the mothers 3 and 9 months postpartum to all mothers (Table 1). At the time of third questionnaire, 14% of the mothers had stopped breastfeeding. One reminder was sent to the mothers who did not respond to the questionnaire. It should be noted that data collection for 3 questionnaires in CGA took place between April 2000 and April 2001, before the intervention could have had effects on the counseling. The data for the 3 questionnaires in the IG and CGB were collected simultaneously from October 2000 to January 2003.
Obstetric data were collected from the birth records. Demographic background data were collected with the first questionnaire (Table 2).
All 3 questionnaires inquired about mothers' relationship with the infant and their maternal feelings for the infant. In the questionnaires, the mothers were asked to reflect on the perception of the relationship with the infant and their maternal feelings for the infant during the same time frame (Tables 3 and 4).
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TABLE 3 Mothers' Responses to Statements About Their Relationship With Their Infant at 3 Days and 3 and 9 Months Postpartum, for the IG and CGA and CGB mothers
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TABLE 4 Mothers' Responses to Statement Regarding Maternal Feelings for Their Infant at 3 Days and 3 and 9 Months Postpartum, for the IG and CGA and CGB Mothers
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Relationship With the Infant and Maternal Feelings for the Infant
Seven statements were included to collect data about the relationship with the infant: "I talk a lot with my infant"; "I know what my infant needs"; "I enjoy resting when my infant is with me"; "My infant is more beautiful than other infants"; "My maternal feelings are very strong"; "I feel that my infant is my own"; "I enjoy breastfeeding a lot." The statements were assessed on a Likert scale with a 7-point response format ranging from "disagree completely" to "agree completely."9
Seven statements were used to gather information about the feelings for the infant. The mother was asked to determine whether her relationship with the infant was "insecure–secure," "unpleasant–pleasant," "not confident–confident," "unstable–stable," "distant–close," "cold–warm," or "difficult–easy." The answers were analyzed using the Likert scale with a 7-point response format.9
Statistics
For the statistical analyses of the results, SPSS (version 11.5; SPSS, Inc, Chicago, IL) was used.10 The end points of the Likert scales were recoded to get all of the positive assessments at the higher end point (Tables 3 and 4). To test the differences between the groups, we performed 1-way analyses of variance when suitable. Tukey's honestly significant difference test was used for posthoc comparisons. Category data were tested by 
2. Central measurements are presented as means and dispersion by SD. P 
.05 was considered significant.
Pilot Test
The 3 questionnaires that were developed for the purpose of the study were pilot tested by 20 mothers for acceptability and face validity. The questionnaire was corrected before data collection began. In addition, an expert group of midwives and pediatric nurses were consulted to establish content validity of the questionnaires. Minor corrections of a few wordings were done.
Ethical considerations
The Ethics Committee of the Medical Faculty of Gothenburg University (Gothenburg, Sweden) approved the study.
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RESULTS
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Dropouts
Response rates for the 3 questionnaires are shown in Table 1. The obstetric data for the participants and the external dropouts did not differ significantly (data not shown).
Demographic Background Data
Demographic background data are shown in Table 2. There were no significant differences between the IG and the control groups with regard to age, educational level, and marital status. There were no significant differences between the groups in regard to the mode of delivery (Table 2). There was a significant difference in exclusive breastfeeding duration between the IG and CGA (P = .02; Table 2).
Perception of the Relationship With the Infant and Maternal Feelings for the Infant
At 3 days postpartum, the perception of the relationship with the infant did not differ between the IG and CGB. In contrast, both the IG and the CGB mothers talked more to the infant than did the CGA mothers (P < .001), they enjoyed resting more with the infant (P < .001), they perceived more strongly the infant as their own (P < .001), and they enjoyed breastfeeding more (IG/CGA: P < .001; CGB/CGA: P = .001) than did the CGA mothers. At 3 months postpartum, no significant differences were found among any of the groups, but at 9 months postpartum, the IG mothers talked more to their infant (P = .001), they perceived their infant as being more beautiful than other infants (P = .001), and they perceived more strongly that the infant was their own (IG/CGB: P = .041; IG/CGA: P = .028; Table 3).
There were no significant differences with regard to the perception of the maternal feelings for the infant between the IG and the CGB mothers until 9 months postpartum (Table 4). At this time, the IG mothers felt significantly more confident with their infant (P = .003) and felt the infant to be more close than did the CGB mothers (P < .001). The IG and the CGB mothers felt more confident with their infant (P < .001) and rated the relationship with the infant as being warmer (P < .001) already at 3 days postpartum than did the CGA mothers (Table 4).
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DISCUSSION
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In this study, we tested the effects of mothers' perception regarding the relationship with the infant on a breastfeeding-counseling program for health care professionals and an intervention plan that aims to guarantee continuity of care. The time frame of the study involved pregnancy through the first 9 months postpartum.
In the first days, there were differences between the IG and CGB compared with the CGA mothers, reflecting a pattern of closeness and confidence in the relationship. If this finding were related to the intervention, then the main contribution to this effect should be ascribed counseling at the antenatal clinic. The IG and CGB mothers also enjoyed breastfeeding more, indicating that breastfeeding started nicely. Taken together, these findings should optimize closeness between mother and child. Other studies indicate that supportive behavior during pregnancy may reduce stress2 and additionally may enhance bonding between the mother and her newborn. In animal experiments, it has been shown that maternal behavior is enhanced by oxytocin release.11,12 Stress disturbs the release of oxytocin and therefore may counteract maternal behavior and maternal feelings also in human mothers. One may speculate that support during pregnancy and childbirth reduces stress in the mother and therefore is of particular importance for the development of the mother–infant relationship. Ultimately, a relaxed mother may open up mentally during breastfeeding to be able to interpret and understand the signals of the newborn infant.11,13 Breastfeeding itself is likely to strengthen the ties between mother and child as a result of physiologic mechanisms such as oxytocin release and stimulating the parasympathetic nervous system, making the mother less anxious and more relaxed.
During the subsequent 3 months after childbirth, there was no difference between the groups. It is interesting that at the 9-month observation, the IG mothers interacted more with their infant, they felt a stronger tie with their infant, and they found their infant more beautiful than other infants when compared with the control groups. This might well be a long-lasting effect of early interaction, facilitated by good counseling. It therefore seemed that supportive behavior from the staff during pregnancy and after the event of childbirth may have a particularly strong effect on maternal feelings and possibly also maternal behavior. One may speculate about the fluctuations of the results of our measurements at the different points in time. At 3 months of age, most mothers had well-established breastfeeding. It is possible that breastfeeding compensated for the differences between the groups at the 3-month observation. Breastfeeding is known to enhance oxytocin release and well-being of the mother and may facilitate her focus on her feelings for the infant at this time in all groups.14 Good social support during pregnancy in addition to breastfeeding may strengthen and prolong oxytocin effects on the development of a warmer and more confident relationship with the infant in the IG group when compared with the other groups. The mental support during periods of openness such as pregnancy may induce long-term effects on the mother–infant relationship. The effects of good counseling may be hidden during breastfeeding and may not become apparent until breastfeeding comes to an end. In Sweden, most women breastfeed for the first 3 months after childbirth, and it may not be possible to observe "pure" effects of supportive counseling.
Supporting behaviors of the postnatal nurse, such as the ones that we observed in previous studies, may lead to empowerment of the mothers and a better self-esteem.1,2 Better self-esteem also may help the mother to attach to her infant.15 Therefore, not only supportive health professionals but also experienced parents could be particularly powerful role models as the self-image of the new parents emerge, and these influences can enhance greatly the self-confidence of the new parents.16 Indeed, previous studies on lay social support during childbirth have shown similar results.17
The response rate in the first questionnaire was 89%. In the third questionnaire, it was 69%. An explanation for this could be that the 3 questionnaires had similar questions and the mothers thought that they had answered them before. Another explanation could be that 66 (14%) of the mothers had ended their breastfeeding at the point in time for the third questionnaire (at 9 months). The methodologic approach in this study, using 2 control groups (the first one before continuing family classes and the other one collected simultaneously with the intervention group) was helpful in learning more about how an intervention such as this should be conducted. More differences were found between the IG and CGA, supportive of the possibility that when an intervention is materializing, changes also take place among the control subjects. If participants who are to be randomly assigned as intervention or control are situated far away from each other, then this might reduce the spillover effects, but it also may bring about other, unwanted effects, such as variety in social structures, etc. In this situation, it might be helpful to use 2 control groups at different points in time to understand better what happens during an intervention, as has been done in this study.
More research should be done to validate the scales on maternal feelings and the relationship with the infant used in this study against attachment and bonding scales. Additional research is needed about mothers' experience of how the quality of support influences psychological adaptations to motherhood.
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CONCLUSION
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A process-oriented breastfeeding training program for antenatal midwives and postnatal nurses that includes an intervention that guarantees continuity of care strengthened the maternal relationship with the infant and the feelings for the infant.
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ACKNOWLEDGMENTS
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This study was supported by the Skaraborg Institute for Research and Development, School of Life Sciences of the University of Skövde; the Primary Care Unit in Skaraborg and the Science Committee, Central Hospital, Skövde; and the Board of Research for Health and Caring Sciences, Swedish Research Council (grants K1999-27P-13085-01A, and K2001-27P-13085-036).
We thank Assoc Prof Ann-Marie Widström and statistician Ann-Sofi Matthiesen, BSc, for valuable comments on the manuscript.
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FOOTNOTES
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Accepted Mar 27, 2006.
Address correspondence to Anette Ekström, PhD, RNM, School of Life Sciences, University of Skövde, Box 408, SE 541 28 Skövde, Sweden. E-mail: anette.ekstrom{at}his.se
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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ABSTRACT
METHODS
