This study aimed to explore breastfeeding support by public health nurses (PHNs) working in Japanese municipalities in order to promote a breastfeeding-friendly environment. We interviewed 20 participants including five PHNs, four midwives, four doctors (one obstetrician and three pediatricians), and seven mothers who experienced breastfeeding between June and August 2010 and analyzed the data using content analysis. Collected data were classified into four categories including “collecting information”, “assessment”, “direct and individual support”, and “support for group and community” with 15 subcategories: infant’s condition, mother’s condition, mother-infant relationship, child rearing environment, mother’s state-of-mind, identifying necessary support, psychological support, concrete support, breastfeeding on demand, necessary information, advice to supporters, introducing services, breastfeeding-friendly environment, breastfeeding support groups and cooperation with relevant organization. This study suggested that the PHNs’ responsibilities for breastfeeding support should be extended beyond the currently understood scope of their duties. The study demonstrated that PNH needed to create a breastfeeding-friendly environment that included networking with breast care support organizations and peer groups and to promote breastfeeding in public areas including the workplace.
Breastfeeding has various health benefits for mothers and children [
Based on the MCH law enacted in 1965, public health nurses (PHNs) who provide home visits and telephone counseling to support mothers and families play an important role in supporting breastfeeding mothers. To increase the breastfeeding rate, PHNs have launched a breastfeeding initiative including group education for mothers, individual counseling, and organizing peer support groups [
We interviewed 20 participants including five PHNs, four midwives, one obstetrician, three pediatricians, and seven mothers who experienced breastfeeding between June and August 2010. PHNs, midwives and medical doctors who had more than 5 years working experience were included in this study. A semi-structured interview was conducted in accordance with the interview guide. The interviews lasted from 50 to 70 minutes.
Ethical approval for this study was obtained from the Ethical Review Committee of the Faculty of Medicine, the University of Tokyo (Clearance No. 3035).
1) Socio-demographic characteristics: sex, age, work experience as a PHN, MW, or doctor, mothers’ breastfeeding experience.
2) Breastfeeding support: What kind of breastfeeding support should PHNs provide?
Qualitative content analysis was used to analyze data [
The median age of the PHNs, doctors, and midwives was 51, 54, and 55 years old, respectively. The median years of employment experience was 9, 25, and 28 years, respectively. Two doctors were male, and the rest of the participants were female. The median age of mothers who practiced breastfeeding was 41 years. The num- ber of children ranged from one to three. The period of breastfeeding ranged from one month to 50 months. The age of children ranged from 1 to 27 years old (
Breastfeeding support by PHNs was classified into four categories and 15 sub- categories. The categories were labeled, “collecting information”, “assessment”, “direct and individual support”, and “support for group and community”. Each category consisted of multiple subcategories as described below.
“Collecting information” consisted of four subcategories including “Infant’s condition”, “Mother’s condition”, “Mother-infant relationship”, and “Child rearing environment”.
“Infant’s condition” was designed to assess the condition of the individual infant. A participant said, “I measure the weight and watch the movements of infants when they are together with their mother. It is important to observe the general condition of infants, not only numerical values like weight”. “Mother’s condition” was designed to assess the condition of individual mother. A participant mentioned, “It is important to observe the mental and physical condition of the mother
| Age | Work experience | Number of children | Age of children | Total period of breastfeeding (months) | ||
|---|---|---|---|---|---|---|
| N | Median (Range) | Median (Range) | Median (Range) | Median (Range) | Median (Range) | |
| PHN | 5 | 51 (28 - 61) | 9 (5.8 - 20) | - | - | |
| Doctor | 4 | 54 (35 - 62) | 25 (5 - 35) | - | - | |
| Midwife | 4 | 55 （40 - 58) | 28 (19 - 31) | - | - | |
| Mothers who experienced breastfeeding | 7 | 41 (31 - 62) | - | 1 （1 - 3） | 4 (1 - 27) | 14 (1 - 50) |
| [Sub-category] | Code | |
| 1) | ||
| (1) | [Infant’s condition] | Measuring weight; observing movements of infant; noting general condition of infant |
| (2) | [Mother’s condition] | Mental condition; physical condition; life style; ideas about breastfeeding |
| (3) | [Mother-infant relationship] | Position during breastfeeding; latching of infant; mother’s expression |
| (4) | [Child rearing environment] | Relationship with husband, family, and friends; living environment; socio-economic situation |
| 2) | ||
| (5) | [Mother’s state-of-mind] | Clarifying mother’s troubles |
| (6) | [Identifying necessary support] | Clarifying degree of independence and understanding; identifying information and support necessary for mother and family |
| 3) | ||
| (7) | [Psychological support] | Providing psychological support for mothers such as approval; listening closely; sympathy; acceptance |
| (8) | [Concrete support] | Providing concrete support when troubled such as coping with failure to lactate; helping underweight infants to gain weight |
| (9) | [Breastfeeding on demand] | Helping mothers to breastfeed whenever they or their infant require it |
| (10) | [Necessary information] | Providing information such as Benefits of breastfeeding; method of breastfeeding; breast care and promoting breast milk to the mother and family |
| (11) | [Advice to supporters] | Advice to supporters such as the husband, family, and friends on providing appropriate mental support to mothers doing breastfeeding |
| (12) | [Introducing services] | Introducing services such as facilities and home visit services providing breast care whenever the mother needs them |
| 4) | ||
| (13) | [Breastfeeding-friendly environment] | Making a local directory of child care services; establishing public breastfeeding facilities; encouraging working mothers to continue breastfeeding; raising awareness about breastfeeding friendly environments |
| (14) | [Breastfeeding support groups] | Forming a peer group to help mothers experiencing troubled with breastfeeding and Introducing breastfeeding support group to mother |
| (15) | [Cooperation with relevant organization] | Sharing information and cooperating with relevant medical institutes and midwives |
and to hear her opinions about breastfeeding”. “Mother-infant relationship” was designed to assess the relationship between mother and infant when the two are together, rather than individually. A participant emphasized, “It is important to observe the position of both mother and infant during breastfeeding, infant latching and the mother’s expression”. “Child rearing environment” was designed to assess the child care environment globally. A participant said, “It is important to understand the woman’s relationship with her husband, family and friends, the living environment and the couple’s socio-economic status when PHN visit the mo- ther’s home”.
“Assessment” of breastfeeding support consisted of two subcategories including “mother’s state-of-mind” and “identifying necessary support”. The former subcategory was designed to clarify the mother’s concerns regarding breastfeeding. A participant reported “It is important to clearly understand the mother’s state-of- mind and any reasons for her feeling concern”. “Identifying necessary support” is a subcategory designed to identify the kind of information or help that mothers and their family require but are lacking. A participant explained, “If the mother experiences difficulty while breastfeeding. The PHN should assess the situation ve- ry carefully from different points-of-view rather than giving a facile assessment and advice to the mother”.
“Direct and individual support” for breastfeeding consisted of six subcategories including “psychological support”, “concrete support”, “breastfeeding on demand”, “necessary information”, “advice to supporters” and “introducing services”.
“Psychological support” was designed to assess the importance of the PHN’s approval of, attention to, sympathy for, and acceptance of, the mother. A participant reported, “If the mother feels any difficulty while breastfeeding and caring for her child. It is very important for the PHN to listen to and accept the mother’s opinions”. “Concrete support” was designed to assess the importance of maternal coping with problems such as the inability to lactate and of helping underweight infants to gain weight. “Breastfeeding on demand” assessed the importance of supporting breastfeeding activity whenever either the mother or infant required it. “Necessary information” examined providing information of the benefits and promotion of breastfeeding, the methods used, and breast care to the mother and family. “Advice to supporters” assessed the importance of advising those close to the breastfeeding mother such as the husband, family, and friends on how to support her emotionally and psychologically. A participant mentioned, “It is especially important to recognize the feelings of the grandparents who used artificial milk to feed the infant”. “Introducing services” addressed the importance of introducing facilities and home visit services providing breast care whenever the mother needs them.
“Support for group and community” for breastfeeding consisted of three subcategories including “breastfeeding-friendly environment”, “breastfeeding support groups”, and “cooperation with relevant organizations”.
“Breastfeeding-friendly environment” assessed the importance of providing a directory of child care services and establishing breastfeeding rooms in public areas. A participant reported, “It is important to advise working mothers to continue breastfeeding and to raise awareness of the importance of having a breastfeeding-friendly environment”. “Breastfeeding-support group” assessed forming a peer group to help mothers experiencing troubled with breastfeeding and introducing breastfeeding support group to mother. “Cooperation with relevant organizations” assessed the importance of information-sharing and cooperation with medical institutions and midwives.
Our research showed that PHNs were expected to play many roles in breastfeeding support. The examples of such roles reported by Hirano [
“Evidence for the Ten Steps to Successful Breastfeeding [
A previous study in Canada showed that a negative breastfeeding support experience was a significant effect modifier on the relationship between breastfeeding difficulties and postpartum depression [
The Ministry of Health, Labour and Welfare [
This study targeted clinical and public health professionals and mothers and therefore did not include feedback from researchers and occupational health nurses. In addition, the results of the assessment of the types of support examined were not included in the results. Further studies targeting a broader demogra- phic are necessary to improve breastfeeding support expected of public health nurses.
This study examined four categories including “collecting information”, “assessment”, “direct and individual support” and “support for group and community” for assessing breastfeeding support and 15 subcategories, namely, “infant’s condition”, “mother’s, condition”, “mother-infant relationship”, “child-rearing environment”, “mother’s state-of-mind”, “identifying necessary support”, “psycholo- gical support”, “concrete support”, “breastfeeding on demand”, “necessary information”, “advice to supporters”, “introducing services”, “breastfeeding-friendly environment”, “breastfeeding support groups” and “cooperation with relevant orga- nization”.
This study suggested that the PHNs’ responsibilities for breastfeeding support should be extended beyond the currently understood scope of their duties. The study demonstrated that PNH needed to create a breastfeeding-friendly environment that included networking with breast care support organizations and peer groups and to promote breastfeeding in public areas including the work- place.
We are grateful to the PHNs, doctors, midwives, and mothers who took the time to participate in our interview. We would also like to express our gratitude to the faculty and members of the Department of Family Nursing, Graduate School of Medicine/Faculty of Medicine School of Health Science & Nursing of the University of Tokyo.
We declare no conflict of interest.
This study was funded by Grants-in-Aid for scientific research expenses of the Ministry of Education, Culture, Sports, Science and Technology (Grant Number 2139 0589).
Noriko Toyama: study design, data collection, data input, data analysis, discussion, and finalized the manuscript.
Mineko Muranaka: study design, data collection, discussion, and reviewing of the paper.
Kayoko Kurihara: study design, data analysis, discussion, and reviewing of the paper.
Kiyoko Kamibeppu: supervised all the processes involved in this study.
Toyama, N., Muranaka, M., Kurihara, K. and Kamibeppu, K. (2017) Qualitative Study of Breastfeeding Su- pport by Public Health Nurses in Japan. Health, 9, 451-458. https://doi.org/10.4236/health.2017.93032