Post-natal care and breastfeeding experiences : a qualitative investigation following a randomised trial of side-car crib use (NECOT Trial)

The World Health Organization recommends that mothers should breastfeed their infants exclusively for six months and continue to breastfeed alongside complementary foods for two years or more (WHO 2003). In the UK breastfeeding initiation is high, however, duration falls significantly short of the WHO recommendations (McAndrew et al 2012). Preserving mother-baby contact throughout the post-natal stay is recommended to safeguard and support favourable breastfeeding outcomes (WHO 1989). The NECOT Trial (a randomised controlled trial involving 1204 mother-newborn dyads) examined whether the provision of side-car cribs during the post-natal stay (facilitating unrestricted contact) resulted in a longer duration of breastfeeding than rooming-in using stand-alone cots. The trial obtained weekly data on infant feeding and sleeping arrangements for 26 weeks post-partum. The use of side-car cribs on the post-natal ward did not improve the duration of any or exclusive breastfeeding in the sample overall (Ball et al 2011). This follow-up research aimed to contextualise the NECOT Trial results by adding a qualitative component to the existing quantitative protocol. Methods Interviews were conducted at approximately six months post-partum with a sub-sample of NECOT Trial participants (64) and a number of post-natal ward staff (19) involved in their care. Aims of the maternal interviews were to investigate mothers’ hospital and at-home experiences of infant feeding and sleeping behaviour and to explore their experiences of participating in the trial. Staff interviews were aimed at investigating perceptions of side-car crib usage and to examine attitudes towards post-natal care and breastfeeding support. Audio recordings of interviews were analysed using NVivo software. Findings were discussed within an authoritative knowledge (AK) theoretical framework. Results The interviews revealed that women randomised to receive the side-car cribs felt that they had made a positive difference to their experiences on the post-natal ward; women randomised to the control group felt a side-car crib would have been beneficial. Participants from both the NECOT intervention and control groups recommended continued use of the side-car cribs on post-natal wards. In particular, the advantage of issuing the side-car crib to women who have mobility issues (delivered via c-section or who had received epidural/spinal analgesics) were highlighted. The benefits of the side-car cribs for breastfeeding were deemed to be outweighed on the post-natal ward by other experiences undermining the establishment of breastfeeding such as the introduction of ‘top-up’ formula feeds, absence of skin-to-skin contact, periods of mother-infant separation, delayed breastfeeding initiation or initial breastfeeding difficulties. Staff identified difficulties working around the side-car cribs and discussed problems relating to their role in providing breastfeeding support on the post-natal ward. There were additional factors within the home environment that had a negative effect on breastfeeding duration beyond the initial post-natal period, such as the impact of caring for other children, returning to work, imposition of a feeding/sleeping routine, beliefs of insufficient milk and feelings that breastfeeding was too demanding/tiring. The results also indicated that the follow-up calls impacted upon mothers’ thoughts and actions regarding infant feeding and sleeping behaviour. An AK framework was shown to be a useful theoretical concept for helping to understand and interpret the research findings. Conclusion The overwhelming positive response to the side-car cribs and the benefits highlighted by NECOT Trial participants suggest that introduction of side-car cribs on post-natal wards will improve patient experience. However, any potential beneficial effects on breastfeeding appear to be easily offset by the various effects of other factors that served to reduce breastfeeding success and duration. This implies that the introduction of side-car cribs may be more effective if introduced in conjunction with other interventions addressing breastfeeding barriers on the post-natal ward and continued support in the community. Moreover, from a broader perspective, the findings of the research challenge the authoritative position of quantitative research and RCTs for informing evidence-based medicine.