岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

＜ Material ＞

An Integrative Review of English and Japanese Language Studies ofMidwifery Education in Relation to Breastfeeding
Shizuko Angerhofer1） Heather Hopper2） Kyoko Noguchi1） Heather Skirton2）
1）Faculty of Nursing, Iwate Prefectural University, Iwate, Japan.
2）School of Nursing and Midwifery, University of Plymouth, Plymouth, PL4 8AA, United Kingdom.

Abstract
The importance of breastfeeding for health and wellbeing is well established. Support of breastfeeding
is a basic competency for midwives and midwifery education should address this topic. The aim of thisintegrative review was to ascertain the evidence regarding effectiveness of midwifery education in relation
to breastfeeding. We used guidance developed by the Centre for Reviews and Dissemination to searchfor, select, appraise and abstract data from relevant papers. Eligible studies were written in English or
Japanese, published since 1989 and addressed pre- or post-graduate midwifery education on breastfeeding.
Of a possible 760 papers, three were included in the review. Three main themes emerged from a thematic
analysis of the results: learning from women, learning in the classroom and learning from practice.
Experiential learning and working alongside midwives who demonstrated good practice was important
to enable student midwives and midwives to become‘skilled companions’to breastfeeding mothers.
However, there is little empirical research on educational interventions designed to help student midwives
and midwives develop the knowledge, skills and attitudes to support breastfeeding mothers. Further
research in this area is required involving both classroom and practice-based teaching.
Keywords:Breastfeeding; Clinical placements; Education; Experiential learning; Midwifery

Introduction

evidence of protection against breast cancer, in addition

The importance of breastfeeding for the health andto some protection against ovarian cancer and type 2

wellbeing of individuals and society is now well establisheddiabetes（Victora et al., 2016）: these effects are universal,

as a result of a growing evidence-base（Horta et al.,so apply to women, regardless of income or nationality.

2015; Sankar et al., 2015; Victora et al., 2016）．This is

However, the prevalence of breastfeeding was identified

supported by reduced mortality rates amongst exclusively

as lower in high-income countries than in low and middle-

breastfed infants compared to those who are either partially

income countries（Victora et al., 2016）．Whilst the infant

or not breastfed（Sankar et al., 2015）．A review of 28

mortality rates in those infants who are not breastfed aresystematic reviews and meta-analyses provided undisputed

lower in high-income countries, the economic impact ofevidence relating to both short and long-term healthlow breastfeeding rates has been shown to be significant.

consequences of breastfeeding（Victora et al., 2016）;

In the United Kingdom（UK），Renfrew et al.（2012）

this study identified that breastfeeding provides infants

estimated that a modest increase in breastfeeding rates

with significant protection against childhood infections,

could save over £17 million annually due to the reduction

increases intelligence, and provides some reduction inof four infant illnesses alone, specifically gastrointestinal

obesity and diabetes. For women who breastfeed, there isdisease, respiratory disease, otitis media, and necrotising─ 39 ─

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

enterocolitis（NEC）.

To promote practices that protect, promote and support
breastfeeding globally, the baby friendly hospital initiative

In addition, there are demonstrable benefits from

（BFHI）was launched as a joint project between thebreastfeeding for infants requiring special care after birth.

WHO and UNICEF（WHO, 2016）in 1991 following the

For example, Tanaka et al.（2009）found that the scores for

Innocenti Declaration（WHO, 1990）． A fundamental

cognitive function tests at 5 years of age were significantly

aspect of the baby friendly initiative（BFI）is the education

higher in the breastfed group among very-low-birth-weight-of staff in order to achieve these aims（UNICEF, 2017a），infants, and Vohr et al.（2007）identified that the benefits

and this therefore includes post-registration breastfeedingof vulnerable babies receiving breast milk whilst in the

education for practicing midwives. Several studies across a

Neonatal Intensive Care Unit（NICU）continued to berange of countries have demonstrated that maternity units

evident at 30 months of age; these benefits included higher

with BFI accreditation have higher breastfeeding initiation

developmental and behavioural scores, as well as fewer

rates than those without accreditation（Munn et al,hospitalisations, compared with babies who did not receive

2016; Cox et al, 2014）．In addition, Sinha et al.（2015）

breast milk.

identified that the greatest improvements in breastfeeding
rates were found in areas where improved support andHaving established the importance of breastfeeding in

education was offered in a range of home, community

terms of both health and cost, it is therefore imperativeand hospital settings; in these circumstances a wide range

to consider how breastfeeding rates can be effectivelyof qualified health professionals would have received

increased. The World Health Organisation（WHO）

additional breastfeeding education.

clearly states that maternity services have a special role inprotecting, promoting and supporting breast-feeding（WHO,

Whilst a review of 15 studies by Ward and Byrne（2011）

1990）．The International Confederation of Midwives

demonstrated that continuing breastfeeding education for（ICM）also highlights the importance of midwives

nurses and midwives improved knowledge, skills, practices

in promoting breastfeeding and supporting women to

and attitudes, no reference was made to pre-registration

succeed（ICM, 2013）．Indeed the initiation and support

breastfeeding education for midwives. However, Wardfor early breastfeeding is listed in the ICM standards as

and Byrne（2011）did recommend that at least 18-20

a basic competency that should be an expected outcome

hours of breastfeeding education should be included inof midwifery pre-service education（ICM, 2013）．In

undergraduate programmes. Since 2008 the UNICEF BFI

addition it is important to note that the promotion ofhas included an accreditation programme with specificbreastfeeding is viewed as a key element in the fourthlearning outcomes for UK university programmes; thesemillennium development goal to reduce infant and childare aimed at Midwifery and Health Visiting/Specialist

mortality（Oruamabo, 2015）．The ICM is committed

Community Public Health Nurse programmes（Cummings,

to promoting evidence-based practice, and enhancing the2008）．With this in place a growing number of midwifery

health of newborn babies is part of their mission statement.

programmes in the UK have developed curricula that meet

Therefore all midwives should be equipped with thethese standards（UNICEF 2017a）by including learningknowledge and skills to support successful breastfeeding.

opportunities related to infant feeding across the duration of

In the UK, the Nursing and Midwifery Council（NMC），

pre-registration programmes, employing a range of teachingwhich regulates the midwifery profession, requires

approaches（Angell & Taylor, 2013）．In Japan also, themidwives to be competent in supporting mothers tonumber of Baby Friendly Hospitals has doubled in the pastbreastfeed（NMC 2009）: equally, in Japan such skills

10 years, and 73 institutions are accredited as of 2016
（Japanare integral to preparing midwives for practice, in line with

Breast Feeding Association 2016）．This enables more

the guidance of the ICM（2013）and“A Statement by

student midwives to be exposed to BFI standards during

Midwives”（The Japanese Midwives' Association, 2010）．

clinical practice placements. In line with Ward and Byrne's（2011）findings relating to a significant change in attitude

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岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

following breastfeeding education, Angell and Taylor

quality assessment of studies and synthesis of the available（2013）suggest that existing attitudes to infant feeding, as

evidence（Centre for Reviews and Dissemination, 2009）．

a result of personal experience, may be a barrier to learning

We used PICOS（Table 2）and the PRISMA guidanceand should be addressed prior to the learning of factualand checklist（PRISMA 2009）to inform the selection ofknowledge.

papers and ensure rigour of the review process.

The institutions of the authors are connected through amemorandum of understanding, the aim of which is to

Search strategy

share and improve educational practice in both nursing

Evidence published in either English or Japanese wasand midwifery. Both institutions support the Baby

considered for inclusion.

Friendly Initiative and we are therefore seeking ways toensure graduate midwives are able to support mothers to

Selection of papers

breastfeed. We therefore decided to investigate the available

We selected papers based on stringent inclusion andevidence through an integrative review, which is designed

exclusion criteria.

to include studies that utilise a range of methodologies

In this study, we defined midwifery education as（Whittemore and Knafl, 2005）．

“Education required for licensure/registration of midwives

Aim of the review
The aim of the review was to ascertain the evidence

Table 1. Search Strategy

regarding effectiveness of midwifery education in relation

Databases and other

The following databases were used to search for

to breast feeding.

sources

appropriate papers: CINAHL, MedlineScience
Direct and PsychInfo（papers in English）．

The objectives were:

CiNii, ICHUSHI web（papers in Japanese）．

1. To identify educational methods used to provide

We also conducted an ancestral search of

midwifery students and midwives with the knowledge,

relevant journals: Midwifery, Journal of Japaneseskills and attitudes required to support mothers to

Midwifery and BMC Pregnancy and Childbirth .
Search terms

breastfeed

The following terms appearing in the title or
abstract were used in the search:

2. To ascertain the effectiveness of those methods in

midwifery OR midwife（midwi*）AND

enabling student midwives and midwives to support

education OR training OR programme OR

mothers to breastfeed.

curriculum OR student AND breast feeding OR
breastfeeding
Dates

Methods

As the document‘10 Steps to Successful
Breastfeeding'（WHO, 1990）was launched byStudy design

UNICEF/WHO in 1989, we searched for papers

Health professional education should be informed bypublished between January 1989 and February

the scientific evidence available regarding good clinical

2017.

practice and effective educational strategies. Conducting
a literature review in a systematic manner can be used toTable 2. PICOS criteria

identify, analyse and synthesise the available evidence

Participants

on a specific healthcare topic（Centre for Reviews andDissemination, 2009）．We used the guidance suggestedby the Centre for Reviews and Dissemination to undertake
this integrative review of midwifery educational practices

post-registration, studying a formal programme ata higher education institution.
Interventions

Education related to breast-feeding

Comparator/

Qualitative data on impact of the intervention

comparison

OR pre and post intervention changes in midwife

used to prepare student midwives and midwives to support
mothers to breastfeed. This involved using a thoroughand systematic search strategy（Table 1），selection ofstudies based on rigorous inclusion and exclusion criteria,
─ 41 ─

Midwifery students, whether pre-registration or

knowledge or skills or attitudes.
Outcomes

Impact of education on student competence

Study designs

Primary research of any type: quantitative,
qualitative or mixed methods.

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

including undergraduate programmes, professional school• Papers focussed on formal midwifery education

programmes, and education in postgraduate programmes（undergraduate or postgraduate programmes orfor licensed midwives”.

programmes required for licensure/registration of

The inclusion criteria were:

midwives）• Papers reporting original research studies, conducted in• Papers related directly to midwives' support of breast

any country

feeding mothers

Identification

Records identified throughdatabase search: CINAHL, Medline,
Web of Science, PsychInfo = 892

Additional records identified
through other sources = 0

Records after duplicates removed = 629

Eligibility

Screening

Records excluded
Not in English = 17
Records screened using
title or abstract
629

Not focussed on midwife
education in BF = 569

Full‐text articles assessed
for eligibility
39

Full‐text articles excluded,with reasons:
Not research =14

IncludedStudies assessed for
quality = 2

Not focussed on student
midwives in higher
education = 17
Student midwives only incontrol group= 1
Commentary = 2

Studies included insynthesis = 2
Fig1. PRISMA (2009) Flow Diagram – English papers

─ 42 ─

Fig1. PRISMA (2009) Flow Diagram – English papers

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

• Papers written in either English or Japanese.

educational papers, opinion papers, reviews• Those focussed on breastfeeding education for healthprofessionals outside formal educational programmes.

We excluded the following papers;• Those not based on research studies, for example

Identification

Records identified throughdatabase searching
CiNii, ICHUSHI web = 132

Two authors（HH and HS for English papers, SA and

Additional records identified
through other sources = 0

Records excluded
Records screened using
title or abstract = 131

Eligibility

Screening

Records after duplicates removed = 131

Full‐text articles excluded,with reasons:

Full‐text articles assessed
for eligibility = 9

Included

Not focussed on midwife
education in BF = 122

Not research = 3

Not focussed on student
midwives = 5
Studies assessed for
quality = 1

Studies included insynthesis = 1
Fig2. PRISMA (2009) Flow Diagram – Japanese papers

Fig2. PRISMA (2009) Flow
Diagram– Japanese papers
─ 43─

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

KN for Japanese papers）reviewed every paper that was

Quality appraisal

identified during the search, to create a shortlist of papers

In order to assess the methodological rigour of the papers

for possible inclusion. Full text versions of those papers

selected, we used the checklists designed by Kmet etwere then read, again by at least two authors, and aal.（2004）．These authors devised a list that can be used

decision made as to the inclusion or exclusion of that paper.

for qualitative studies, and another for quantitative studies.

Throughout this process, all four authors discussed theTwo authors（HH and HS for English papers, SA and KN

selection to ensure the criteria were being applied equitably

for Japanese papers）assessed each paper independently andto both English and Japanese papers.

met to discuss any discrepancies in the appraisal of each.

The selection process is illustrated in Figure 1（English

Guidance from the Centre for Reviews and Dissemination

papers）and Figure 2（Japanese papers）．Of a total of 760（Centre for Reviews and Dissemination, 2009）indicates

papers identified as potentially for inclusion, 48 were readthat selection of papers based on a numerical score may notin full text and three were selected for the final review.

be robust, but the quality appraisal is an indicator of theTable 3. Characteristics of the three included studies
Authors, year, title, country
Blackman et al（2015）

Aim

Study design and method‘To:（i）determine if midwifery

Pre and post intervention survey.

students' self-reported abilities in

Participants
95 undergraduate
midwifery students atUsing Rasch analysis to identify

teaching and supervising breastfeeding

The intervention was a programme of study

one higher education

midwifery students' learning

mothers vary;（ii）assess whether（delivered as part of the undergraduate midwifery

institution.

about providing breastfeeding

the midwifery students' self-rated

programme）on infant nutrition comprising 36 hours

support.

breastfeeding ability tool is anof tutorials, and 108 hours of self-directed learning.

appropriate and reliable method
Australia.

of measurement; and（iii）explore
what differences exist between
midwifery students' self-rated abilities
for breastfeeding teaching andsupervision between two time periods,
approximately six months apart'．
（p229）

Taylor & Hutchings（2012）‘to explore the impact of an educational

Qualitative study based on thematic analysis. This

Eleven students

was originally part of a sequential mixed methods

from a post-graduate

Using video narratives ofintervention using women's video

study but the quantitative phase data were not

midwifery programmeomen's lived experience of

narratives of their lived experience ofreported.

in one higher education

breastfeeding in midwifery

breastfeeding and guided learning

education: exploring its impact

institution. The students
The intervention comprised a programme of study

were experienced

on midwives' attitudes tomaterial on midwives' attitudes toon supporting breastfeeding in which students

midwives before

breastfeeding.

providing support for breastfeeding

were asked to watch video diaries compiled bystarting the programme.

women'（p90）

breastfeeding mothers, complete a workbook, reflect

United Kingdom

on their practice and consider possible changes totheir own practice.

Shinohara et al.（2012）
Contents of lessons learned

To identify students' learning in

The midwifery students' learning in their midwifery

heir midwifery clinical experiences

clinical experiences was analysed from their clinical （4th year of a university

practicing with midwives.

report by KJ methods.

by midwifery students during
maternity home practice Japan.

─ 44 ─

Four midwifery students
nursing programme）

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

level to which the results of each study can be trusted. We

emerged from each study: these are reported in Table 4.

therefore included all the identified studies.

We then used a thematic analysis approach to analyse datathat emerged from the qualitative studies, using the method

Data abstraction  suggested by Braun and Clarke（2006）．To achieve this,Each paper was studied by at least two authors and table ofeach paper was read by two authors several times and initialindividual characteristics of each study was prepared（Table

codes were identified. The codes were then discussed and3）．As there was considerable variance in methods used,organised under themes that emerged naturally from theneither meta-analysis nor meta-synthesis could be used todata（Table 5）．The results of this phase of the analysis

analyse the data.

are presented in narrative form（Centre for Reviews andWe used a three-step approach similar to that previously

Dissemination, 2009）．

used in other healthcare reviews（Paalosalo-Harris andSkirton 2017）．First we summarised the topics that

Data collection

Data analysis

Main findings

The tool was based on a previously

Rasch analysis was used to

34 of the original 37 items were found to be valid; measuring the samedeveloped breastfeeding self-efficacy

create a hierarchical linear scale, underlying attribute. The tool incorporating these 34 items was found to bescale（Dennis, 2003）, with someplotting the perceived difficulty

additions and a brief pilot, resulting inof the activity against the ability

37 items.

of the student.

reliable.
Of the 34 activities included in the analysis, five activities were perceived by
students to be more difficult post-intervention. These were: helping mother

Students self-rated their ability for each

The outcomes pre-intervention

to comfortably breastfeed in public places, helping her to hold her baby

item using a 4 point Likert scale.

and post-intervention were then

comfortably during breastfeeding, encouraging her to feed her baby every 2–3

compared.

hours, helping her focus on getting through one feed at a time and providing

Pre-intervention survey completed

her with a rationale for feeding overnight.

on day 1 of the maternal and infant

A hierarchical linear scale

nutrition topic; post-interventionof difficulty of breastfeeding

Five activities were perceived to be easier: helping mother determine if baby

survey completed on the first day ofactivities was drawn up forhad sufficient milk, helping her to take her baby off the breast without pain to

the following semester（6 months later,

both pre and post-intervention

the nipple, motivating her to breastfeed successful, encouraging her to feed herfollowing some postnatal experience insurveys.

baby only breast milk and enabling her to assess when her baby had finishedaddition to the taught topic）．
Two focus groups were conducted: fivebreastfeeding.
Thematic analysis.

Six themes were identified: listening and learning fromparticipants in one, six in the other.

women's experiences, generation of emotions; acquisition of new knowledge
and learning, reflection on practice, promotion of independent learning andsharing learning with peers.

In the students' daily clinical report, theThe data was categorised using

sentences include the words; learned,

KJ method. Then the categories “Efficacy of health guidance”,“Importance of reconfirmation of knowledge”,

6 categories were,“Midwife techniques”,“Midwife diagnostic methods”,

understood, or realized, were collected

were compared in theiras data.

relationship.

“Supporting breastfeeding”, and“Role of midwife in practice”.
These contents included required assignments from the practice, implying thatstudents could understand the role and supporting methods of midwives inpractice.

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岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

Table 4. Topics emerging from the included
studies

Two of the studies focussed on undergraduate midwifery

Categories of findings

programmes, while students of the other were in a

Blackman

Taylor andShinohara

postgraduate programme（Taylor & Hutchings, 2012）．

et al. 2015

Hutchings.

et al., 2012

The number of participants ranged from four（Shinohara et2012

al., 2012）to 95（Blackman et al., 2015）．

PG students
Difficulty of skill

X

There was a total of 10 topics that emerged, and they

Self-rated ability of students

X

reflected the findings of each study, such as acquisition

Changes in self-rated abilityXof new knowledge and learning and reflection in practice.

after education
Learning from women's

Then the topics were compared and categorised into sub-X

themes.

experiences
Generation of emotions
Acquisition of new

The over-arching theme that emerged from analysis of

X
X

X

X

Reflection in practice

X

X

Promoting independentX

the three papers was‘enhancing student midwives andknowledge and learning

midwives’knowledge, skills and attitudes’．Within thismajor theme we identified three sub-themes that we labelled‘learning from women’,‘learning in the classroom’andlearning
Sharing learning with peers‘learning in practice’．We present the narrative account ofX

Learning from experiencedX

our analysis under these sub-themes.

midwives in practiceLearning from women
Table 5. Themes and sub-themes

Under this theme, a sub-theme of listening to women's

General theme: Enhancing midwives' knowledge, skills and attitudes

experiences emerged. However the only authors to address

Sub-theme

Categories under thisPapers in which this sub-this directly were Taylor and Hutchings（2012）．As

theme

theme appeared

Learning from

Listening to women's

Taylor & Hutchings（2012）

part of a post-graduate module on breastfeeding, thewomenexperiences

authors showed videos of real women speaking about

Generation of emotions

Taylor & Hutchings（2012）

their breastfeeding experiences and their interactions with

Learning in

Independent learning

Taylor & Hutchings（2012）

midwives. These were used in conjunction with guided

the classroom

Sharing with peers

Taylor & Hutchings（2012）

Changes in self-rated

Blackman et al（2015）

workbooks. Although the eleven midwives in the groupwere experienced, they reported that the videos enabledability after education
Acquisition of new

Taylor & Hutchings（2012）

them to see the issues from the women's perspectives, inknowledge

Blackman et al（2012）

ways they had not previously done. They appreciated the

Learning fromWorking with

Shinohara et al.（2012）

practiceexperienced midwives

feedback and reflected that in their daily practice they were

Reflection in practiceoften more focussed on tasks and less on what women

Taylor & Hutchings（2012）

felt and needed from them. Another interesting reflection

Shinohara et al.（2012）
Difficulty of the skill

concerned the need to be practising safely, with an

Blackman et al（2012）

acknowledgement that if the primary driver was to protect
women and babies from harm, then that meant women

Results

were less able to exercise choice around how they fed their

In the review, two papers were written in English: one study

babies. They felt that the educational videos helped them towas conducted in Australia（Blackman et al., 2015）and

re-focus on the women.

one in the United Kingdom（Taylor & Hutchings, 2012）．

The second sub-theme under the theme of learning fromIn the one paper written in Japanese, the authors reported awomen was generation of emotions. Midwives reported

study conducted in Japan（Shinohara et al., 2012）．The

that seeing women express their feelings created feelings ofcharacteristics of each individual study are presented in

empathy and admiration for the women, but also frustration,

Table 3.

defensiveness, shock and guilt（Taylor & Hutchings,
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岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 20202012）．For example, it came as a shock to realise that

rated ability scores to assign the relative difficult of tasks.

some women had strong negative reactions to midwives

Changes in self-rated ability of each task were calculated

touching their breasts when supporting breastfeeding. Someand a logit score for each item was produced. Where a

midwives felt that women did not always appreciate thedifference of less than one logit between pre and post

relative priorities of care, for example that commencing

course ratings occurred, the perceived difficult of the task

breastfeeding might not be appropriate if the mother's life

was said to be unchanged. Following the theory component

was in danger. It must be remembered that only elevenand practical experience, they reported least confidence in

midwives, from one educational institution, were involved

their ability to help the mother understand that she neededin this study, so the findings may not be transferable toto feed 2-3 hourly, to feed on demand, to increase supply

other contexts.

by feeding overnight, and explain benefit of breastfeeding.
However, they had most confidence in their ability to assess

Learning in the classroom

if the mother was satisfied with her experience, to explain

In the study by Blackman et al.（2015），95 midwiferythat breastfeeding can be time-consuming and to show

students were asked to complete a survey before and after

the mother how to take baby off the breast without nipple

a course on infant nutrition, in which breastfeeding wasdamage. The authors indicated that a difference of morea major component. The taught component of the course

than one logit indicated a change, and was considered bycomprised 36 hours of tutorial time, with a further 108

the authors to indicate that learning had occurred. One ofhours of self-directed learning. While clinical placements

the weaknesses of this study is that while learning about

were not built in to this course, the student midwives were

the difficulty of the tasks may have occurred, this does notreported to have clinical placements in postnatal settingsnecessarily indicate that student midwives had learnt moreduring the six month period of the course, connected with

about how to perform it effectively.

other parts of their training. Learning therefore may have

Although initially midwives in the study by Taylor andtaken place via classroom teaching or in clinical practice.

Hutchings（2012）reported they had not learnt anything

As the details regarding the amount and type of clinicalspecific from the use of videos in classroom teaching, it

practice were not stated, we have included the results underbecame obvious during focus group discussions that they

the‘learning in the classroom’theme. At the start of theintended to change practice（e.g. by encouraging skin to

six month course, student midwives rated their confidence

skin contact after Caesarean section），therefore learning hadin performing a range of skills related to supporting

occurred. They also reported that their assumptions aboutmothers to breastfeeding. At the beginning of the course,

their practice with women had been strongly challenged by

the skills student midwives felt most confident about

the video recordings and this had also precipitated changes

were: conveying the fact that breastfeeding can be time-in practice. Midwives reported that having protected time

consuming, explaining the need for skin to skin contact

during the course to reflect outside everyday practice

immediately after birth, helping the mother to hold her

was also valuable, however this may have been the casebaby comfortably while feeding, getting friends to support

for any course and may not have been due to the specificher decision to breastfeed and assessing whether the mothereducational intervention. However, it was clear that much

was satisfied with her experience of breastfeeding. Skillsof the coursework was delivered via guided workbooks,

student midwives felt least confidence in performing

so the student midwives needed to be highly motivated to

were: encouraging mother to feed 2-3 hourly, helping the

maximise the learning opportunities. Student midwives inmother obtain family support and explaining benefits ofthis study indicated that peer support（via fellow students）

breastfeeding to her. However, six months later, at the end

helped them to deal with the emotions generated by theof the course, their assessments of their own abilities had

mother's accounts.

altered somewhat. The student midwives had spent clinicaltime in postnatal wards during this period, and therefore

Learning from practice

had experience in practice. The authors used the self-

Shinohara et al.（2012）reported on the experience of─ 47 ─

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

undergraduate midwifery students while on a maternity

resolved to alter practice, for example by prioritising tasks

placement. In this study, the daily clinical documents

differently, by acting as a stronger advocate for the motherwritten by four undergraduate midwifery students during

and by promoting the mother's independence.

their 2-week clinical experience were analysed by the‘KJ’method（a form of qualitative analysis suggested

Discussion

by Jiro Kawakita（Scupin, 1997）. The authors reported

While there has long been an acknowledgement that healththat student midwives learned how to support the mothers

professional education related to breast feeding has an

by working with experienced midwives. The six major

impact on breast feeding rates, this has been emphasised

themes identified were:‘Midwife techniques’, ‘Midwife

again in a very recent systematic review by Burgio et

diagnostic methods’,‘Efficacy of health guidance’,al.（2016）.

‘Importance of reconfirmation of knowledge’,‘Supporting

Swerts et al.（2016）indicate that breast feeding support

breastfeeding’and‘The role of the midwife in practice’.

is more acceptable to mothers when midwives adopt

Focusing on the category‘Supporting breastfeeding’,

the role of‘skilled companion’, rather than‘technicalmothers were provided with breastfeeding support andexpert’. This involves a‘hands off’approach and a focus

information throughout pregnancy and the breastfeedingon the relationship between the mother and the infant,period, with emphasis on the relationship between

which may develop through experiential learning. In thisbreastfeeding and the infant's health status. Midwives werereview, it was clear from the findings in two studies thatobserved responding sensitively to the mother's feelings,

learning in practice was valuable for student midwives.

the student midwives particularly described learning fromThe students in Shinohara et al.'s study（2012）reported

midwives' attitudes towards mothers and their approaches tolearning from midwives in the clinical setting, however, inmaking suggestions based on their assessments, explaining

this regard effective learning is dependent on observation

concepts concretely, and giving positive feedback toof appropriate practice. Where student midwives weremothers. The strength of this setting was the opportunity toobserving poor practice, for example where midwives wereobserve midwives working autonomously but closely withworking more as‘technical experts’who regarded mothers

mothers. However, Shinohara et al.（2012）conclude thatas novices（Swerts et al., 2016）, this could result in themwhile breastfeeding support is an important midwifery role,developing poor habits and attitudes that could work

it is difficult to learn sufficiently about it through clinicalagainst successful breastfeeding. In the study by Blackman

experiences during the pre-registration period and this must

et al.（2015）, it was clear that having experience inbe built on after registration. However, the author suggests

clinical practice changed not only the perceived expertisethat having the opportunity to experience breastfeeding careof students, but also their appreciation of the complexity of

by working with midwives in a clinical maternity setting issome activities involved in supporting breastfeeding.

valuable for student midwives.

The use of video accounts to enable post graduate students

The results of the study by Blackman et al.（2015）haveto access the views and experiences of mothers was shown

been described above, but they may indicate that clinicalto be a particularly powerful teaching tool（Taylor andexperience in postnatal settings had taught the student

Hutchings, 2012）．

midwives that those tasks that required encouraging theAngell and Taylor（2013），writing about the challenges

mother（who may well have been tired as a result ofof preparing student midwives to support breastfeeding,labour）to feed frequently, including throughout the night,

commented on the negative attitudes towards particularwere more challenging.

types of infant feeding held by some student midwives.

On a negative note, midwives attending a postgraduate

These may be based on their own previous experience

course（Taylor & Hutchings, 2012）indicated that theof infant feeding, although ideas about feeding may bepressures of working in practice were so great that thisformed at a much younger age（Angell et al., 2011）．

inhibited them from reflecting and also from giving womenAngell and Taylor（2012）discuss methods of challenging

the support they needed. Several midwives in that study

midwives' longstanding beliefs so that they can offer─ 48 ─

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

support, regardless of the mothers' chosen mode of feeding.

age, indicating that the first six weeks of the baby's life are

Inclusion of direct input into the classroom teaching, ascrucial in establishing breastfeeding. However, mothers

well as by clinical experience may be effective in helping

who stopped breastfeeding in the first week of their baby's

student midwives and midwives to empathise with mothers

life cited problems with attaching the baby, sore breasts,

and support their decisions. Registered midwives in theand insufficient milk as reasons for not continuing: thesestudy by Taylor and Hutchings（2012）reported that they

are all issues that a midwife is trained to help the motherhad been unaware of mothers' feelings about feeding andto address and indeed, mothers who would have wishedthey were shocked by some of the video accounts. In

to continue feeding for longer reported that they felt morethis case, the ability to have insight into practice requires

support from midwives would have helped them to do

experience, as a result this method could be effective forso（Health and Social Care Information Centre, 2012）．

qualified midwives. However, midwifery education should

These results are confirmed by results of a review by Jamesaim to produce midwives who are not only supportive of

et al.（2016）that indicated midwifery support had amothers' choices, but also able to communicate effectively

considerable impact on mother's ability to breastfeed afterwith women during this critical period for establishingearly discharge from hospital. However, cultural barriers

breast feeding（UNICEF, 2014）．

now exist in the UK because of low breastfeeding rates

WHO guidelines enable many mothers around theand the trauma of trying to breastfeed but not succeedingworld the chance to receive standard global support of（UNICEF, 2017b）; as a result it is perhaps unsurprisingbreastfeeding. In addition, the basic principles regardingthat some mothers feel unable to continue to breastfeed.

breastfeeding are universal. While the ability to support

In turn, this links with the negative attitudes towards

mothers to breastfeed is clearly stated by the ICM as abreastfeeding held by some student midwives and midwives

competence that is essential for midwives internationallyas they embark on their midwifery education（Angell et al.,（ICM, 2013），in some countries the re-allocation of2011），and has resulted in breastfeeding in the UK having

midwifery resources works against this. For example, in

become a very emotive topic（UNICEF, 2017a．

the UK breastfeeding support for mothers is increasingly
assigned to lay peer supporters or to unregistered staff

Strengths and limitations of this study

such as maternity support workers（Griffin et al., 2010）．

While we followed the guidance of the Centre for Reviews

In addition, it is reported that Child Health Nurses andand Dissemination（2009）to conduct this review, the fact

General Practitioners also provide breastfeeding support

that there were only three studies identified for inclusion

in Australia（Cox, 2017）． Therefore, the skills required

limits the findings. In addition, the three studies varied

to coordinate a variety of supporters could be included

hugely in terms of the research question and methods used,

for midwives in their education. In this climate of care,making meta-analysis or meta-synthesis impossible.

the essential experience needed by midwives to support
mothers appropriately could be reduced. In contrast, in

Implications for educational practice.

Japan, mothers receive care from either registered nurses

It is clear from this review that in respect of breastfeedingor registered midwives. There are substantial differences

education, midwives benefit from practice in clinicalin the initial breastfeeding rates in these countries（98%settings. The foundation of knowledge is important, butbabies in Japan are breastfed at least once, compared tofurther time for practice and reflection has been shown to

81% of babies in the UK），which is potentially at least

help the midwife develop his or her role in this area. We

partly due to the involvement of midwives in encouraging

would suggest that refresher courses in which qualified

breastfeeding. Data available on duration of breastfeeding

midwives are encouraged to reflect on their own practice arefrom the most recent UK infant feeding survey, conducteda useful contribution to midwifery practice. This would also

in 2010,（Health and Social Care Information Centre,

help to ensure that student midwives are working alongside2012）shows that exclusive breastfeeding drops from 69%

competent practitioners when on clinical placements.

at birth, to 46% at one week of age, to 23% at 6 weeks of─ 49 ─

岩手看護学会誌／ Journal of Iwate Society of Nursing Science.Vol.14, No.1, 2020

Conclusions

30(4）:488-497. doi: 10.1177/0890334414547274. Epub

The educational methods used to provide midwifery

2014 Aug 19.

students and midwives with the knowledge, skills andCox K, Giglia R, and Binns C W.（2017）Breastfeeding

attitudes required to support mothers to breastfeed are;beyond the big smoke: Who provides support for mothers

learning from women, learning in the classroom, andin rural Western Australia? The Australian Journal oflearning from practice. Post graduate midwives were able to

Rural Health 25: 369-375.

witness breastfeeding issues from the women's perspectives

Cummings, M.（2008）Best practice standards forby watching video of breastfeeding women speaking. As

breastfeeding education: A baby friendly approach. Nurse

a result, this learning from women's experiences gave

Education Today 28(8）: 895–898.

midwives a new awareness of breastfeeding support as

Griffin, R., J. Dunkley-Bent, J. Skewes et al.（2010）．

it relates to women's emotions. The self-rated ability

Development of maternity support worker roles in theof student midwives was altered by learning in the six-

UK. British Journal of Midwifery 18(4）: 243-246.

month infant nutrition course. Learning from experienced

Health and Social Care Information Centre, IFF Research

midwives in practice, helped the student midwives learn（2012）Infant feeding survey 2010. Available at: http://

how to support breastfeeding mothers by observing

content.digital.nhs.uk/catalogue/PUB08694/Infant-experienced midwives being close to the women. These

Feeding-Survey-2010-Consolidated-Report.pdf Accessededucation methods for student midwives and midwives led

March 28, 2017
Horta, B. L., C. Loret de Mola and C. G. Victora（2015）．

to acquisition of new knowledge and learning.

Long-term consequences of breastfeeding on cholesterol,

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＜資料＞

助産教育における母乳育児に関する
英文および和文論文の統合的レビュー
アンガホッファ司寿子 1） ヘザー・ホッパー2） 野口恭子 1） ヘザー・スカートン 2）1）岩手県立大学看護学部

2）プリマス大学看護・助産学部

要旨
母乳育児支援は助産師の基本的コンピテンシーであり，助産教育において扱われるべきトピッ
クである．本レビューの目的は，母乳育児に関連した助産教育の有効性のエビデンスを確認することとした．論文検索，選択，データ抽出は，Centre for Reviews and Dissemination のガイダンスを使用し，助産教育における母乳育児支援に関連した論文を対象とした．
760 件の論文のうち 3 件を対象とした．結果の主題分析から，＜女性から学ぶ＞＜講義で学ぶ＞＜実践から学ぶ＞の 3 テーマが抽出された．母乳育児をする母親にとって身近な存在の熟練助産師になるためには，経験的な学びと，よい実践をする助産師と一緒に関わることからの学びが重要であった．しかし，助産学生および助産師が母乳育児支援するための知識，技術，態度の教育的介入に関する実証的研究はほとんどない．講義と実践，両方の教育が関連したさらなる研究が求められる．
キーワード：母乳育児，臨床実習，教育，経験的学習，助産─ 52 ─