Can a phone call make a difference? Breastfeeding self-efficacy and nurse responses to mother’s calls for help

Abstract

Telephone support is a format that presents an opportunity to sustain breastfeeding at a time when mothers identify themselves as at risk of cessation. The interactive mechanisms by which support is provided have not, however, been well investigated. We aimed to identify characteristics of calls that support breastfeeding self-efficacy. Thematic analysis of 149 calls from mothers seeking help for breastfeeding made to a 24-hour parenting helpline over a four week period, in Brisbane, Australia. Call-takers were 12 qualified and experienced maternal and child health nurses. Calls classified according to changes in breastfeeding self-efficacy across the call were thematically analysed to identify distinguishing interactional characteristics. Key interactional characteristics that served to build self-efficacy were privileging the mother, teamwork and credible affirmation while those that failed to build self-efficacy were laissez-faire affirmation and pragmatic problem-solving responses. Nurse responses that undermined caller self-efficacy conceptualized breastfeeding as a problem. Telephone helplines have potential to enhance mothers’ confidence and sustain breastfeeding when there is a call for help, this study highlights that the style of interaction is critical. The findings identify the need for specific training to increase awareness of interactional styles and delivery of advice through telehealth formats.

Keywords

Breastfeeding qualitative approaches self-efficacy telephone support

Introduction

Breastfeeding is consistently associated with a variety of health benefits for both mother and child (Horta and Victora, 2013a, 2013b). Children who are breastfed in infancy have lower risk of obesity and chronic disease (Horta and Victora, 2013a) and demonstrate better cognitive performance (Mortensen, 2015; Nyaradi et al., 2015). Recognizing breastfeeding’s diverse health benefits, international recommendations are for exclusive breastfeeding until six months of age with breastfeeding complementing other foods to at least 24 months.

While a majority of women know that breastfeeding is the best option for their infants (Brodribb et al., 2007), a range of physical and psychological factors often threaten their willingness and ability to sustain breastfeeding (Thulier and Mercer, 2009). In addition to non-modifiable factors (maternal age, education and income), sociocultural, environmental and other personal determinants may influence breastfeeding behaviours (Brand et al., 2011; Meedya et al., 2010). One of these is self-efficacy, a fluid and modifiable predictor of breastfeeding duration and a significant target for intervention (Dennis, 1999).

Understanding mechanisms to improve breastfeeding self-efficacy represents an important focus for evaluating support interventions. The findings of a recent systematic review concluded that women benefited more from ongoing support in areas with high initiation rates; support could be provided by both peers and professionals; face-to-face consultations were more successful; and interventions where women are expected to initiate contact are unlikely to be effective (Renfrew et al., 2012). While these findings raise questions about the general uptake of telephone support, where women initiate assistance, this support format presents an opportunity to sustain breastfeeding at a time when mothers are at risk of cessation (Henshaw et al., 2015; Thomson and Crossland, 2013; Thomson et al., 2012). To date, there is little information on the nature and content of the interactions and how these might influence self-efficacy. The current study examined reactive telephone support provided to mothers seeking support for breastfeeding through analysis of 149 calls to a parenting helpline. The aim was to identify effective telephone helpline support assessed using a self-efficacy frame. Qualitative analysis examined changing expressions of breastfeeding self-efficacy during interactions.

Methods

Data consisted of de-identified telephone conversations between nurses and callers accessing the Child Health Line, a 24-hour telephone support resource operating from a specialist, government funded parenting centre in Queensland, Australia that provides parenting advice and information. The telephone conversations were recorded over four weeks from mid-December 2005 until early January 2006 as part of a research study conducted by Danby and colleagues (2009). Over this period, 723 phone calls were recorded covering a variety of parenting and child health issues. The present study sampled calls from this corpus focusing on breastfeeding concerns.

Ethical approval for the original study conducted Danby and colleagues (2009) was obtained from the Queensland University of Technology Human Research Ethics Committee and the Royal Brisbane Women's Hospital Ethics Committee (approval no. 4121H). Under the ethics agreement, nurses and callers were able to withdraw calls. Ethical approval to access and analyse calls for the present study was obtained from the Queensland University of Technology Human Research Ethics Committee Human Research Ethics Committee.

Identification of calls for analysis

To be included, calls needed to relate to infants, with breastfeeding as the call content. ‘Infants’ were defined using the World Health Organization’s definition of optimal breastfeeding, including all children aged two years and below. Using these criteria, all 723 telephone conversations were scanned audibly. When a call was unlikely to include content related to infant feeding, the call content was sampled in approximately 30-second increments to ensure no mention of infant feeding was made. Calls were excluded if only incidental enquiry was made regarding feeding method and if feeding did not become the focus of the counselling. All infant feeding calls were documented including breastfeeding, bottle-feeding and introduction of solids (N = 248 calls); of these, 149 (60%) focused on breastfeeding.

Participants

Nurses

Twelve nurses, who staffed the Child Health Line during the study period, participated. All participating nurses held a general nursing degree and postgraduate qualifications in midwifery and/or child health but had not received any specialized training in telephone counselling.

Callers

Callers were members of the general public accessing the Child Health Line from urban, regional and remote Australian locations seeking advice on infant feeding. Callers were predominantly mothers (93%, n = 138), although a small proportion were fathers (6%, n = 7) or other family members or friends (1%, n = 2). Permission for caller inclusion was obtained at the open of calls.

Characterization of calls

Callers’ demographic variables were recorded on a research pro forma from information provided within the call, including infant age, caller’s relationship to the child and postcode of callers. Postcodes were classified according to the Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD) (Australian Bureau of Statistics, 2011) which provides an estimate of relative socio-economic status.

Analysis

Self-efficacy as informed by social cognitive theory was the lens through which the telephone calls were analysed and operationalized as having emotional, cognitive and behavioural components. Self-efficacy is defined as an individual’s evaluation of their ability to successfully execute a given behaviour. Such evaluations form what Bandura termed ‘efficacy-expectancies’, which moderate the likelihood to either persevere with or avoid behaviours in expectation of mastery or failure respectively (Bandura, 1977, 1986). Importantly, self-efficacy is distinguished from ‘outcome expectancies’, which represent one’s appraisal that a given behaviour will lead to a certain consequence. This distinction is made, as while there may be positive evaluations of the consequences of a particular behaviour, decreased self-efficacy can thwart its execution (Bandura, 1977, 1986). This is the case for infant feeding, where knowledge of the health benefits of breastfeeding can be undermined by reduced confidence in determining its performance (Chezem et al., 2003). Trajectory of mother’s breastfeeding self-efficacy across the call (improved, unchanged, reduced) was coded using a standard protocol assessing change from opening to close of call (inter-rater reliability assessed on a subsample showed satisfactory agreement (ICC = 0.78 for cognitive, 0.75 for emotional and 0.74 for behavioural self-efficacy).

Thematic analyses of the 149 calls were undertaken following Braun and Clarke’s (2006) protocol to identify trends for further analysis in a manner that captured the original context in which they occurred (Namey et al., 2007). Detailed analyses of calls were undertaken assessing interactional style, strategies associated with self-efficacy response and impacts of interactional style on call outcome.

In initial analyses, all calls seeking breastfeeding support were listened to in full at least twice for data familiarization. For each call, the primary researcher (CC) documented key features, quotes, content and recurring themes. In further iterative consultation with the raw data, inductive generation of selective and then axial codes was undertaken. Emergent themes relating to interactional style and self-efficacy outcomes were then further compared to the raw data and refined. This data reduction process follows recommendations for maximizing credibility and dependability of findings in large qualitative data sets (Namey et al., 2007).

Qualitative rigour

To ensure qualitative rigour, three qualitative methods of triangulation were employed: data, researcher (Olsen, 2004) and interdisciplinary triangulation (Janesick, 1994). Data triangulation was achieved by incorporating data from multiple participants with coverage of a naturalistically sampled range of issues pertaining to breastfeeding. Researcher triangulation occurred through independent coding of a sample of seven call transcripts by three researchers (CC, KT and DG) (Tobin and Begley, 2004). As the researchers worked within two different disciplines, Psychology (CC and KT) and Nutrition (DG), inter-coding also comprised interdisciplinary triangulation (Janesick, 1994).

Results

Description of calls

Although the service was accessed by callers across the full range of social class (by IRSAD), callers with breastfeeding concerns were predominantly from higher socio-economic areas (M = 7.31, SD = 2.75). Of those callers (83%) that gave their suburb of residence, 20% (n = 25) resided in a low socio-economic area (IRSAD rating of five or below) and 80% (n = 99) in more advantaged areas.

Breastfeeding queries were made to the Child Health Line about children from age groups spanning the prenatal period until 20 months of age. The service was most frequently accessed for breastfeeding issues across the first three months of life with highest numbers in the first postpartum weeks (see Figure 1).

Figure 1.

Calls to helpline for breastfeeding support by infant age (weeks).

A variety of issues were presented in breastfeeding calls. The four most frequent reasons for calling were for advice about general breastfeeding problems (24.8%, n = 37); breastfeeding and an infant’s bowel movements (16%, n = 24); breastfeeding routine related to sleep problems (14.1%, n = 21); and guidelines for breastfeeding and the introduction of solids (12.8%, n = 19). Of the 37 calls relating to general breastfeeding problems, advice was most often sought regarding: breastfeeding technique (n = 10); an infant suddenly ceasing breastfeeding (n = 7); maternal pain and/or mastitis (n = 6); or milk supply (n = 5).

Thematic analysis

The thematic analysis (see Figure 2) suggests a nurse’s influence on breastfeeding self-efficacy occurs within a rich and complex context. Prominent within this context were medical and moral discourses, which directed and filtered the nurse’s responses to the caller. Most notably, a medical discourse often prompted a ‘question and answer’ interaction format and underpinned the advice provided. The moral discourse was more prominent in directing responses that failed to build or undermined self-efficacy and centred on implicit judgments of mother’s feeding behaviour as ‘right’ or ‘wrong’. These filters were deployed to varying degrees depending on the interactional style.

Figure 2.

Summary of thematic analysis of breastfeeding calls.

The medical discourse: Medicalizing breastfeeding

As would be expected from health professionals, the medicalization of breastfeeding informed the advice given in a majority of cases. This strong medical discourse meant that nurses approached breastfeeding discussion in a formulaic manner and took a pragmatic approach to problem-solving, implicitly emphasizing a clear power differential between nurse and help-seeker. For example, some nurses prescribed rather than negotiated a solution, thus privileging their medical expertise over the mother’s experience.

Nurse:

‘ok then. What you really need to do mum, is you need to try and umm, take her off the breast and put her back to sleep again’.

Mother:

‘ok’.

Nurse:

‘so offer her both breasts, when you are feeding, 15minutes on each breast or a little bit longer on the first one. And then…’.

Mother:

‘so no longer than that?’

Nurse:

‘no 15 or 20 minutes is quite long enough’. Call #ZC5CJ8199

Nurses using this formulaic approach often only discussed a mother’s wellbeing in relation to ensuring the infant was receiving optimum nourishment.

The formulaic approach was the extreme end of the medicalization discourse. Even in cases where nurses worked with mothers in a team approach – the advice given was informed by the biomedical underpinnings.

The moral discourse: Moralizing breastfeeding

Some nurses approached breastfeeding support in a less sympathetic, more judgmental manner. This positioned mothers who were experiencing breastfeeding challenges as selfish or weak when they considered ceasing breastfeeding. In this respect, the infant-centred approach was not only a product of pragmatism, as evidenced when nurses took a medicalized formulaic approach, but the consequence of a moral discourse positioning breastfeeding as a maternal duty fulfilled by ‘good mothers’. As shown in the following quote where, although subtle, judgement is present:

Nurse:

‘and I know it’s Christmas in a few days, so you’ve got to decide, you know, if you really want to breastfeed then you’ve got to let other things go for a little while, especially until your breastfeeding is really well established’ (In response to a mother describing feeling exhausted and considering ceasing breastfeeding). Call #ZC5CJ8199

This moral discourse extended to implicitly polarizing breast and formula feeding, with nurses distinguishing between behaviour congruent with that of a mother who breastfeeds and behaviour that is not:

Nurse:

‘…someone who is breastfeeding wouldn’t resort to the bottle like you have done’. Call #ZC5CS231

In other calls, nurses implicitly placed blame on the mother for being the source of breastfeeding problems.

Nurse:

‘the loose poos mum, two things – has he got a bug that he has picked up from somebody or somewhere, or secondly what have you eaten that may have given him that. So what we are looking at is, how frequently are you feeding him…?’ (bold text is emphasized by the nurse) Call #ZC613J17R

Interactional styles

Coding identified the interactional styles of three self-efficacy trajectories across calls: building, failing to build and undermining self-efficacy. Thematic analysis identified key interactional strategies within these calls. These relate to formulation of the presented issue, positioning of the mother and use of affirmation to caller.

Building self-efficacy

Analysis revealed three broad themes reflecting characteristics of support associated with increased self-efficacy; Privileging the Mother, Teamwork and Credible Affirmation.

Privileging the mother

Support that was more often associated with an increase in self-efficacy was mother-centred, where nurses privileged the mother’s personal breastfeeding experiences, knowledge and opinions over their own. For example, when assisting a mother querying about the introduction of solids, a nurse responded:

Nurse:

‘yep it’s sounding good, and as long as you feel as though the balance is there, you know getting enough breast milk, you can let her have what she wants, but if you felt as though the balance was getting distorted and she’s eating too much solids and not getting enough milk, that might be a time that you do need to cut it back a little bit’.

Mother:

‘yep ok, alright well that’s good to know’. Call # ZC5CKH000

Teamwork

Some nurses also encouraged mother’s participation in finding solutions or making breastfeeding decisions by fostering a sense of teamwork. This still utilized the medical filter, however, nurses invited mothers to contribute. For example, when discussing managing an infant’s feeding and sleeping routine a nurse asked:

Nurse:

‘if she wakes up in a few hours’ time, have you got some strategies that you could use rather than going straight to the feeding?’

Mother:

‘ahh with like, stalling her a bit? Yeah,…she likes laying on her belly and what not’.

Nurse:

‘ok great, so you can give her some floor time’. Call #ZC5CQF270

Credible affirmation

Some nurses affirmed the success of mothers’ breastfeeding practices in a manner that qualified the encouragement provided. Most commonly this was done through visceral evidence for the success of breastfeeding that a mother could reference herself. This strategy was frequently employed when discussing the number of wet nappies an infant had had, to assure the mother that she had sufficient milk supply:

Nurse:

‘Ok, then that’s fine!…Those [wet and soiled nappies] are all good indications that he’s getting, sort of enough milk from you, ok?’ Call # ZC617G545

Similarly, when a mother expressed concerns about breastfeeding, nurses provided a rationale to substantiate their reassurance. For example, in response to one mother believing that she was not feeding well due to her infant not passing many bowel movements, a nurse replied:

Nurse:

‘they seem to at this age, absorb a lot of their feeds, it’s quite a normal phenomenon in breastfed babies that are thriving. So, you know, while he’s gaining weight and wet nappies and content, it’s all good…it’s a really common thing in a breastfed baby to hang on to it [faeces] for a few days’. Call #ZC5CVB53A

Additionally, nurses sometimes acknowledged the difficulties faced when breastfeeding to affirm the mother’s perseverance, and normalize their experiences:

Nurse:

‘…you, are doing a great job, ok? It’s hard breastfeeding, it’s as I said, it’s a learned thing…all a baby knows is how to open their mouth and suck, and sometimes they don’t even know how to suck properly’. Call #ZC617G545

Overall, support associated with an increase in breastfeeding self-efficacy was characterized by the nurse actively listening and involving the mother in arriving at solutions.

Failing to build self-efficacy

Two broad sub-themes characteristic of support that neither fostered nor undermined, but rather, failed to support breastfeeding self-efficacy were identified, namely Laissez-Faire Affirmation and Formulaic Support.

Laissez-faire affirmation

Some nurses provided superficial, flippant or vague affirmation, doing little to encourage mothers, often despite the mother probing for elaboration. For example, when trying to encourage a mother who was having difficulties breastfeeding a nurse avoided providing any direct advice stating:

Nurse:

‘you just keep doing whatever they told you to do when you left the hospital and everything will be fine’. Call #ZC656327I

Pragmatic problem-solving

The pragmatic problem-solving approach was formulaic in content and strongly infant-centred; the approach clearly articulated the medical discourse. This formulaic support format also created a clear reluctance to address broader concerns such as interpersonal support needs, with nurses avoiding addressing callers’ emotional concerns in favour of medical-oriented issues. This is demonstrated in the following case study.

Nurse:

‘Hi how are you? Well you are miserable obviously’.

Mother:

‘yeah…’.

Nurse:

(abruptly) ‘so, umm, is the mastitis in both sides or just one side?’ (information provided by woman’s partner at the beginning of the call).

Nurse:

‘…it’s really about comfort until then and umm, and, but, maintain your fluids and rest for yourself…(trailing off). The other thing is, if your milks coming in at a rush – are your bra’s reasonably supportive but not digging in anywhere and causing any restriction?’

Mother:

‘I don’t think so, they don’t feel like it…’

Nurse:

*talks over mother*…‘because sometimes if you feed bub, and your bras sort of all bunched up underneath, you know it can actually impede the flow…umm, from some areas…from some ducts, and you know you really just need to make sure that you are not impeding it there at all…’ (bold shows that the nurse becomes louder when the mother tries to interrupt).

Mother:

‘ok’. Call #ZC5CNE04T

Undermining self-efficacy

Elements of support that undermined caller’s breastfeeding self-efficacy problematized breastfeeding. This interactional style had a strong moral discourse.

Problematizing breastfeeding

Nurses who approached support in a pragmatic and medicalized manner sometimes focused on a problem, not originally specified by the caller; thus problematizing breastfeeding.

Nurses also passively problematized breastfeeding by confirming a mother’s concern as a problem, without offering constructive solutions.

Problematizing in more implicit ways, nurses often relied heavily on developmental norms as the ‘gold standard’ for comparison, with little responsiveness to the context of the mother-infant dyad. This resulted in nurses prescribing advice based on ideals: often inherently positioning individual experiences as deviating from ‘normal’. For instance, when discussing feeding routine, a nurse stated:

Nurse:

‘have you found that you are feeding a bit more frequently?’

Mother:

‘well I mean I’m feeding less frequently I guess. She was feeding six times now she’s probably four or five’.

Nurse:

pause (3 seconds) ‘and she’s only three months?…hmm I’d probably still be looking at five to six feeds rather than four to five’. Call#ZC614C20H

Discussion

This study has examined telephone interactions between nurses and callers to an Australian 24-hour child health helpline in addressing breastfeeding concerns. Self-efficacy, a modifiable maternal response, was the primary lens for viewing these interactions. Qualitative thematic analysis identified two primary lens used by nurses to filter the type of support provided: medicalizing and moralizing. These in turn influenced the interactive practices relating to maternal self-efficacy: those that supported, those that failed to support and those that undermined self-efficacy. Consistent with existing qualitative research examining face-to-face interactions, those in telephone interactions that were mother-centred (privileging the mother, teamwork) and responsive to mothers’ expressed concerns were found to foster self-efficacy whereas directive, reductionist (formulaic), baby-centred advice and judgmental (problematizing) attitudes undermined self-efficacy (Entwistle et al., 2010; Schmied et al., 2011; Sheehan et al., 2009).

Professional support and breastfeeding self-efficacy

As evidenced by this research, healthcare professionals, especially child health nurses and midwives, are well placed to support mother’s breastfeeding confidence. In addition to often being the first point of contact for breastfeeding support, many women seek professional support for breastfeeding, particularly in the first postpartum weeks (Hailes and Wellard, 2000). The role of healthcare providers in supporting breastfeeding self-efficacy also extends beyond the immediate postpartum period, with Hoddinott et al. (2012) finding that mothers experienced periods of reduced confidence in ability to breastfeed at pivotal points across infant development, and frequently sought professional support with such challenges. A significant corollary of these findings is that breastfeeding self-efficacy may be most vulnerable within the early postpartum period, and at times of crisis across the infant’s development: corresponding to times where mothers frequently receive or seek professional support. In this study, which focused on out of hours requests for help on a telephone helpline, the potential for support at time of ‘crisis’ presents a particularly important focus in which effectiveness of interactions can strongly impact women’s confidence (Thomson and Crossland, 2013; Thomson et al., 2012).

This study provides evidence that professional support does not always impact breastfeeding self-efficacy positively. This aligns with previous research findings where women have found professional support insensitive or unhelpful; in some instances prompting their decision to discontinue breastfeeding (Bäckström et al., 2010; Hauck et al., 2011; Hoddinott et al., 2006, 2012). Importantly, this study also provides evidence that professional support via telephone has potential to promote breastfeeding self-efficacy and highlights components of support that may help achieve this.

Such findings represent a broader distinction observed in the literature, between interactional styles that are facilitative of breastfeeding self-efficacy as opposed to those that are reductionist and constraining (Schmied et al., 2011). In the context of telephone helplines, interactional style has been shown in this study to be critical to mothers’ breastfeeding self-efficacy.

The interactional devices identified in thematic analyses (problem formulation, positioning of caller and affirmation style) indicate that many nurses provided support that was effective in building mothers’ breastfeeding self-efficacy. They also illustrate prevalent practices that undermined, or were ineffective at enhancing self-efficacy. This failure to provide support was likely not benign. Women who received unhelpful professional support are more likely to have lower breastfeeding self-efficacy and cease breastfeeding (Hoddinott et al., 2012). Some professional support provides unrealistic expectations and increases sense of inadequacy rather than building self-efficacy (Fox et al., 2015). These studies along with our findings identify the significance of the qualities of the professional intervention in supporting breastfeeding self-efficacy.

Variations in professional support

A variety of explanations may exist for the immense variation observed in support practices. One important consideration is that the nurses, although specialist qualified maternal and child health nurses, had not received any formal training in providing telephone support. This may have rendered nurses largely unprepared or perhaps even lacking confidence to adequately provide support to breastfeeding women in the helpline context (Butler et al., 2009). Strom et al. (2006) reported that nurses often felt that they were in a vulnerable position delivering support via telephone, which sometimes led them to be defensive or guarded in their support provision. This may explain the findings in the current study where nurses tended to avoid emotional concerns, instead providing support from a medical perspective. These behaviours may be interactional strategies employed by nurses to reframe problems within their field of competency (Butler et al., 2009; Danby et al., 2009). An alternative explanation for the variation in support is that the nurses lacked clear understanding of breastfeeding confidence.

The dual medical and moral discourses through which nurses filter the advice they provide have been previously identified as possible barriers to supporting breastfeeding. Burns et al (2012) identify that the ‘mechanistic biomedical professional discourse’ could subvert ‘the objectives of the health promotion discourses, turning women away from their “machine-like” breastfeeding bodies’ (p. 1744). The moral discourse is pervasive, and within a medicalized expert discourse has conflated breastfeeding with ‘good mothering’ (Marshall et al., 2007; Knaak, 2010).

Strengths and limitations of the study

The strength of the study is the analysis of real time breastfeeding support in a context where many women were vulnerable to breastfeeding cessation. This represents an innovative method for exploring the relationship between breastfeeding self-efficacy and professional support. Nonetheless, this observational method may have invited interpretational bias despite efforts to overcome this potential issue. Multiple researchers rated and coded calls and a comprehensive data record was kept for transparency of research decisions.

Bias in callers participating in the study may similarly be present as women calling the helpline were potentially demonstrating higher self-efficacy by initiating assistance. A strength of the study however was that callers represented a variety of self-efficacy presentations and support needs, and arguably a sample of women most open to sustaining breastfeeding with appropriate support.

Conclusion

The telephone helpline provides a conundrum. On the one side it is an important resource providing needed expert-endorsed advice that potentially buoys mother’s confidence. On the other hand, it is the tangible evidence of the medical and moral discourses with a potential to undermine that confidence (Andrews and Knaak, 2013). The findings of this research prompt the need for further training of telehealth professionals in the provision of breastfeeding support and components of breastfeeding confidence as well as an understanding of the medical and moral discourses that filter the advice given to mothers, regardless of support medium. A mother’s breastfeeding self-efficacy can be strongly impacted by interactions with healthcare professionals: in some instances with potentially lasting negative consequences for mother and child. Telephone support for breastfeeding can make a difference to breastfeeding duration if the process of providing support enhances rather than undermines self-efficacy.

Footnotes

Acknowledgement

The authors wish to thank the nurses and parent callers who consented to participate in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Data collection was supported by a grant from the Children’s Hospital Foundation, Brisbane and Perpetual Trustees.

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