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Abstract

BACKGROUND:

In view of the lack of attention and predictability in postpartum breastfeeding in primiparas, health education on breastfeeding during pregnancy should be carried out to publicize the benefits of breastfeeding.

OBJECTIVE:

To investigate how well the primiparas during pregnancy are known of breastfeeding knowledge, and to provide a basis for developing health education measures for them.

METHODS:

With the adoption of the objective sampling method and the principle of saturation, 10 primiparas in the obstetrics outpatient department of the Hunan Provincial People’s Hospital were selected as the study participants. Semi-structured in-depth interviews combined with the observation method were used for data collection. The interview data were analyzed and the theme was refined by Colaizzi’s seven-step method.

RESULTS:

The results of the four themes of the cognition of breastfeeding knowledge among primiparas were as follows: Lack of knowledge and curiosity about breastfeeding in some women, lack of access to correct breastfeeding knowledge, insufficient support from family members for postpartum breastfeeding, and lack of approach to solve problems during breastfeeding among primiparas.

CONCLUSION:

Due to the current problems of the cognition of breastfeeding knowledge in primiparas, it was imperative to build a health education model suitable for primiparas to improve this knowledge.

Keywords

Primipara pregnancy breastfeeding knowledge cognition qualitative research

1. Introduction

Breastfeeding is a bridge of emotional communication between the mother and her child. It has incomparable advantages over other feeding methods. Breast milk may enhance the immunity of infants and young children and promote their development. In recent years, with the further development of baby-friendly hospitals, the national health administration has done a lot of work to promote breastfeeding, but the effect is unsatisfactory. Survey data [1, 2, 3, 4, 5] show that the current situation of breastfeeding in China is not optimistic. There is insufficient supervision, advocacy, and specific guidance. The lack of public understanding of breastfeeding knowledge, especially the lack of timely, accurate, and individualized guidance for primiparas, and the backwardness of the breastfeeding health education model affect the development of breastfeeding and lead to a low breastfeeding rate. Pregnancy, giving birth to babies, and postpartum breastfeeding are the three most important stages during the reproductive age of women, which is an important period for women of childbearing age for a healthy pregnancy, safe birth, and postpartum recovery. It is also a critical period to ensure proper nutrition for infants and young children. In view of the lack of attention and predictability in postpartum breastfeeding in primiparas, health education on breastfeeding during pregnancy should be carried out to publicize the benefits of breastfeeding [6, 7, 8, 9]. Efforts should be made to increase the enthusiasm of pregnant women and their family members to participate in learning about breastfeeding during pregnancy. With the adoption of case sharing, the problems and solutions during breastfeeding should be analyzed, and the approach to solve possible problems in postpartum breastfeeding should be enhanced. Primiparas did not receive systematic breastfeeding-related knowledge during pregnancy and could not master correct breastfeeding knowledge and skills. At the same time, there are breastfeeding books on the internet, videos on social media, and official accounts that failed to be certified by relevant administrations, so their quality varied greatly. When primiparas had problems during breastfeeding and took improper measures to solve them, it caused unnecessary injury [10]. There is a wealth of research on breastfeeding, but most focus on the effects of caregivers or interventions on breastfeeding. For example, Zhang’s study [11] pointed out that systematic psychological guidance and health education intervention for pregnant women with complications on the basis of routine nursing guidance can help improve the awareness and breastfeeding rate of mothers. The discussion of maternal breastfeeding knowledge is more from the perspective of self-efficacy to analyze [12]. Therefore, in this study, qualitative research on the knowledge of breastfeeding in primiparas during pregnancy was conducted to investigate how well the primiparas during pregnancy are known of breastfeeding knowledge, and to provide a basis for developing health education measures for them.

2. Material and methods

2.1 General material

The target population was primiparas during pregnancy. The age of the pregnant women in the interview ranged between 25 and 34 years, with the gestational age ranging between 26 ${}^{+1}$ and 37 ${}^{+2}$ weeks.

The study was approved by the local ethics committee. The nurses in the outpatient department first contacted the pregnant women. All pregnant women were interviewed and provided informed consent. The random principle was adopted.

2.2 Study methods

2.2.1 Literature research

The research team was composed of five staff members, including the chief nurse, supervisor nurse, nurse, and midwife. The literature was searched with the keywords “Breastfeeding,” “Qualitative research,” “General Information Questionnaire,” “Knowledge Questionnaire of Breastfeeding for Primiparas,” and “Self-efficacy Scale of Breastfeeding for Primiparas”, which were used to investigate and analyze the knowledge and self-efficacy of breastfeeding, its status quo, and its influencing factors. The correlations between cognition, beliefs, and the feeding intentions of breastfeeding in primiparas were explored, and influencing factors were analyzed. Based on the system theory (multidisciplinary study of the general theory of various systems, whose aim is to clarify general principles that can be applied to various systems. It emphasizes that a system is a whole composed of some interacting parts, which is closer to holism than reductionism), holistic nursing theory (an emerging nursing mode, nurses should strengthen the patient’s own attention, but also need to pay attention to the patient’s environment, mental state, physical factors and other factors affecting the recovery of the disease), and Maslow’s theory of basic human needs (from the bottom of the hierarchy up, the needs are physical (food and clothing), safety (job security), social needs (friendship), respect and self-actualization), and combined with the physiological and psychological characteristics of the primiparas, five questions were finally determined as the content of the present interview through preliminary interviews with the primiparas and multiple rounds of expert discussions and revisions.

2.2.2 Cross-sectional investigation

The intentional sampling method was adopted and 10 primiparas who gave birth in the Hunan Provincial People’s Hospital and met the inclusion and exclusion criteria were selected as the study participants for the qualitative interviews. The inclusion criteria were: ⟀ Women with singleton pregnancy; ⟁ Pregnant women aged $>$ 20 and $\leqq$ 35 years; and ⟂ Pregnant women who provided informed consent and volunteered to participate in the present study. The exclusion criteria were: ⟀ Pregnant women with obstetric complications or comorbidities, such as severe heart disease or AIDS and ⟁ Pregnant women with insufficient mental states and cognitive functions who would not be able to cooperate with the researchers. The number of interviews was based on the principle of saturation. Before the interview, the researcher would make an appointment with the interviewee for the time and place of the interview, become familiar with the interviewee’s basic information, and inform the interviewee of the subject of the interview and the research contents. During the interview, the researcher first gave a self-introduction, and with the consent of the interviewee, a recording was conducted, and the contents of the key statement were recorded. The interview time was within 30 min, and the interview was stopped when the interviewee’s opinion was fully expressed. The interview started with open-ended questions, followed by follow-up questions, rhetorical questions, repetitions, and summaries. According to the respondents’ answers, the interviews were gradually deepened.

2.2.3 Collect and sort out data

Conduct data sorting and analysis at the same time, use iFlyHear APP for field recording, convert audio into text and import into computer. The team members listened to the audio recording of the APP, checked, modified, added and extracted the text for many times, and recorded the key information according to the audio recording.

The seven-step analysis method of Colaizzi was used to read the data repeatedly. Group members took the following actions together: ⟀ listened carefully to all the recordings; ⟁ extracted the important statements in the recording information; ⟂ coded the repeated ideas; ⟃ collect the encoded ideas; ⟄ write detailed declarative ideas without omissions; ⟅ identify similar ideas; ⟆ then return the ideas to 10 pregnant women to determine the final topic.

The team members listened and read the material several times, coded the repeated ideas, and encoded the important information with meaning. According to the coding common concepts and characteristics of the summary, the formation of primipara knowledge of breastfeeding cognition consisted of 4 themes.

3. Results

3.1 Lack of knowledge and curiosity about breastfeeding in some primiparas during pregnancy

As is shown in Table 1, the age composition of the primiparas ranged between 25 and 34 years old, and 50% of them were older than 30. The distributions of the ethnicity were: three ethnic minorities were Yao, Tujia, and Miao, and the other seven were Han. The places of residence were: seven lived in provincial capital cities, and three lived in non-provincial capital cities. As for the educational background, all the enrolled primiparas were undergraduate and above, and those with a postgraduate degree accounted for 50%. In terms of employment and place of residence, 70% of the primiparas had stable jobs, lived in provincial capitals, and had relatively stable incomes.

Table 1
Composition of the interview sample

Coding number	Age	Educational background	Ethnicity	Place of residence	Occupation	Gestational age at interview	The weight of the newborn
(Kg)	Gestational age at delivery	History of pregnancy and delivery
A1	34	Undergraduate	Han	Capital city	Bank staff	26 ${}^{+3}$	3.4	37 ${}^{+5}$	G ${}_{2}$ P ${}_{1}$
A2	28	Doctoral degree	Yao	Capital city	Medical staff	36 ${}^{+2}$	3.5	39 ${}^{+6}$	G ${}_{1}$ P ${}_{1}$
A3	34	Postgraduate	Han	Non-capital city	Lawyer	36 ${}^{+4}$	3.8	39 ${}^{+2}$	G ${}_{1}$ P ${}_{1}$
A4	31	Doctoral degree	Han	Capital city	Company staff	36	2.9	41	G ${}_{3}$ P ${}_{1}$
A5	28	Undergraduate	Tujia	Non-capital city	Self-employee	34	3.0	38	G ${}_{1}$ P ${}_{1}$
A6	34	Doctoral degree	Han	Capital city	Financial staff	37 ${}^{+2}$	3.2	40 ${}^{+1}$	G ${}_{2}$ P ${}_{1}$
A7	29	Undergraduate	Han	Capital city	Teacher	35	3.0	38	G ${}_{1}$ P ${}_{1}$
A8	29	Undergraduate	Miao	Capital city	Self-employee	36 ${}^{+3}$	3.4	39	G ${}_{2}$ P ${}_{1}$
A9	33	Undergraduate	Han	Capital city	Nurse	26 ${}^{+1}$	3.5	39 ${}^{+6}$	G ${}_{13}$ P ${}_{1}$
A10	25	Undergraduate	Han	Non-capital city	Freelance	31 ${}^{+2}$	3.6	38 ${}^{+1}$	G ${}_{1}$ P ${}_{1}$

The interviews were carried out mainly from five aspects, and the specific contents and interview results are shown in Table 2. It is shown in Table 2 that 30% of the primiparas did not know about breastfeeding-related knowledge during pregnancy, and 50% of them answered that they did not know how to obtain breastfeeding knowledge. The analysis of the above factors shows that the cultural level and regional differences are not the factors that hinder the breastfeeding of primiparas during pregnancy but the lack of factors. The lack of knowledge about breastfeeding during pregnancy is mainly related to the desire of primiparas to learn about breastfeeding. Primiparous women lack intellectual curiosity about breastfeeding during pregnancy.

3.2 Lack of access to correct breastfeeding knowledge in primiparas during pregnancy

Question ⟂ in Table 2: What are the sources of getting breastfeeding knowledge?

Table 2
Results of the five topics of the interview in ten primiparas during pregnancy

Primipara	The details in the questions
	⟀ Do you want to breastfeed after delivery?	⟁ Do you know anything about breastfeeding?	⟂ What are the ways to gain breastfeeding knowledge?	⟃ How well does the family support breastfeeding?	⟄
A1	Want	Partially understood	Shared by other mothers in the pregnant mother group	The family recommends adding formula milk in the case of insufficient breast milk	So far so good, I did not consider the question.
A2	Be eager to	Understand but not comprehensive	Shared by colleagues	Not very supportive of exclusive breastfeeding	Prolactinist, obstetrician
A3	Want	Understand but not comprehensive	Website browsing	My mother recommends adding formula milk	Not know
A4	Want	Partially understood	Parenting books, Pregnancy classes, Parenting official accounts	Very supportive	Breastfeeding clinic, breastfeeding hotline, and medical consultation
A5	Want	Not understand	Not know	Not very supportive	Not know
A6	Want	Partially understood	Parenting official accounts	With the suggestion of adding formula milk	Obstetric consultation
A7	Be eager to	Not understand	Not know	Not very supportive	Not know
A8	Be eager to	Partially understood	Tik Tok, website,	With the suggestion of adding formula milk	Not know
A9	Want	Understand but not comprehensive	Parenting books and official accounts	Supportive	Department of breast consultation
A10	Want	Not understand	Not know	Not very supportive	Did not consider the question

The three primiparas A5, A7, and A10 answered “Don’t know,” accounting for 30%; however, A1, A2, A3, A4, A6, A8, and A9 obtained breastfeeding-related knowledge through the “Pregnant mothers’ group,” “Colleagues,” “Website browsing,” “Parenting books,” “Tik Tok,” and “Parenting official account.”

The above information shows that 70% of pregnant women obtain breastfeeding knowledge from different ways without normalization, and 30% of pregnant women do not know where to obtain breastfeeding knowledge, which indicates that primiparas lack the right way to obtain breastfeeding knowledge during pregnancy. Therefore, it is imperative to seek a suitable breastfeeding health education model for the current stage.

3.3 Insufficient family support for breastfeeding primiparas

Question ⟃ in Table 2: How well does the family support breastfeeding?

Primiparas A4 and A9 answered that family members were very supportive, and A4 had multiple ways to obtain breastfeeding knowledge, such as parenting books, pregnancy school classes, parenting official accounts, etc. A9 obtained breastfeeding knowledge from parenting books and official accounts. However, the three primiparas A5, A7, and A10 clearly stated that their families did not support breastfeeding. Furthermore, the five primiparas A1, A2, A3, A6, and A8 said that their families suggested adding formula milk for mixed feeding.

3.4 Lack of approached to solve problems during postpartum breastfeeding in primiparas

The following is an analysis of the interview results of the 10 primiparas who answered five questions. Question ⟀: Do you want to exclusively breastfeed after giving birth to babies? All 10 primiparas answered “I would like to” or “I would be eager to.” However, for question ⟁ (“Do you know about breastfeeding?”), the three primiparas A5, A7, and A10 answered “Don’t understand,” accounting for 30%. The four primiparas A1, A4, A6, and A8 answered “Partially understand,” accounting for 40%, and the three primiparas A2, A3, and A9 answered “Understand but incomprehensive,” accounting for 30%. For question ⟂ (“What are the current ways of acquiring breastfeeding knowledge?”), five primiparas, including A5, A7, and A10, answered “Don’t know.” For question ⟄ (“What are the ways you can follow to solve problems concerning breastfeeding after childbirth?”) the four primiparas A3, A5, A7, and A8 answered “Don’t know,” and only A2, A4, A6, and A6 answered that the way to get help was to find a “Prolactologist,” a doctor in the department of breast health, a breastfeeding clinic, or a breastfeeding consultation telephone. The summary and analysis of the interviews with the 10 primiparas revealed that 60% of them did not consider possible problems in postpartum breastfeeding during pregnancy or how to solve these problems.

4. Discussion

Professional women face obstacles when transitioning between their roles [6]. 50% of the participants answered that they did not know how to obtain breastfeeding knowledge, indicating that the primiparas lacked knowledge about breastfeeding during pregnancy. Currently, many women take on different roles. With the analysis of the relevant information on the 10 primiparas, it was suggested that modern women had a high educational background and great social responsibility. And at the same time, the support of their family members was not enough. This led to a lack of attention to breastfeeding, weak curiosity about breastfeeding-related knowledge, lack of access to correct breastfeeding knowledge, and lack of approach to solve possible problems during breastfeeding. The breastfeeding situation is not encouraging. According to the Survey Report on Influencing Factors of Breastfeeding in China released in 2019 [13], the rate of exclusive breastfeeding for infants aged 0–6 months in China was 29%. Ten pregnant women were interviewed, among whom 6 were not considered, accounting for 60%.

4.1 Development of courses related to breastfeeding during pregnancy for primiparas

Targeting the above situations, the research team searched for information and literature with summarization and initially developed special health education courses for primiparas on breastfeeding during pregnancy, such as “The golden 72 hours of lactation”; “Did you eat right in the postpartum golden week?”; “Things about breastfeeding”; “Prevention of breast soreness”; and “How to maintain enough milk.”

4.2 Conduction of health education on breastfeeding-related knowledge for primiparas as planned

The researchers strictly followed the plan and regularly carried out health education on breastfeeding-related knowledge for primiparas.

4.2.1 The contents of breastfeeding knowledge education

The contents of breastfeeding knowledge education were as follows. Emphasize that frequent and effective sucking was a key factor in promoting milk secretion and that skin-to-skin contact between the mother and child was conducive to the establishment of the parent-child relationship and could meet their common health needs. Adopt real-case analysis to enhance the primiparas’ ability to predict problems during postpartum breastfeeding and avoid misunderstandings. Help primiparas and their families establish a scientific view of breastfeeding, ensure smooth milk secretion, balance the supply and demand of milk secretion with the needs of the baby, and prevent breast tenderness during breastfeeding. Ensure successful postpartum breastfeeding for primiparas, increase the interest of primiparas and their family members in postpartum breastfeeding, and enhance their curiosity about breastfeeding-related knowledge.

4.2.2 The forms of breastfeeding knowledge education

According to the results of the qualitative interviews, some primiparas had access to breastfeeding knowledge through “Tik Tok,” “Parenting official account,” and “Parenting Books.” After discussion, the research team organized traditional face-to-face courses about breastfeeding-related knowledge into a booklet, which formed the first and second volumes of 100 questions concerning breastfeeding and were distributed among pregnant women. At the same time, the key knowledge, skills, and case analysis were produced into Tik Tok videos and uploaded there on the parenting public account “Love Rain” to increase the interest of pregnant women and their families in learning. This could also help with obtaining family members’ support for postpartum breastfeeding to prevent the helplessness and loneliness primiparas feel during postpartum breastfeeding [14].

4.3 Problem-solving-oriented breastfeeding clinics and internet consultations for case education and individualized guidance

The time, location, consultants, and registration methods of breastfeeding clinics were publicized, so that primiparas with abnormal nipples could receive professional and timely guidance. Breastfeeding consultants simulated the case management model of high-risk pregnant women to manage primiparas with abnormal nipples to prevent difficulties in seeking help after giving birth to babies. The primiparas were informed about online consultation so that they could find a way to solve breastfeeding problems after they returned home and avoid breastfeeding failure and frustration due to the inability to seek help. Breastfeeding consultants carried out targeted health education and specific skill guidance for primiparas and their families through the empowering education model based on the abnormal nipples of primiparas. This was done to effectively improve postpartum breastfeeding self-efficacy, master breastfeeding knowledge and skills, enhance confidence in insisting on breastfeeding after giving birth to babies, improve the ability to actively overcome problems, solve problems during breastfeeding, and effectively improve the success rate of breastfeeding [15].

4.4 Implementation of the “three early” of breastfeeding and seizing the key link to successful breastfeeding

“Three early” refers to early skin contact, early sucking, early milk. The members of the research team assisted the newborn to connect the nipples correctly within 1 hour after delivery, to implement the early skin contact, early sucking and early milk form the mother. The mother implemented the “three early” to stimulate the breast and establish early lactation reflex so as to grasp the key link of the success of breastfeeding to solve the practical problems of the mother and the baby, and to strengthen the confidence of the mother and the baby connection psychologically and physically to lay a solid foundation for the success of breastfeeding.

4.5 Extending postpartum services and establishing good social and family support systems

From the answers to questions ⟁ ⟂ ⟃ ⟄, shown in Table 2, it was not difficult to find that the support of family members had a certain correlation with how the primiparas acquired breastfeeding-related knowledge, their degree of knowledge mastery, and how they found ways to solve postpartum breastfeeding problems. Therefore, getting support from family members was very critical. It was necessary to correctly assess the actual needs of mothers and their families in regard to breastfeeding and encourage mothers to implement breastfeeding correctly after giving birth to babies. Family members were necessary for assisting mothers in breastfeeding, establishing confidence, and solving problems.

According to the requirements of maternity and child institutions, hospitals transfer postpartum women after discharge to the community service center, which could achieve a good seamless connection between the hospital and community. At present, the staff of community service centers have different levels of serviceability and cannot meet the needs of postpartum breastfeeding, so the new professional “prolactologist” emerged. Ma and Lv [16] showed that there is a controversy about the “prolactologist” in the domestic maternal and infant industry. Liang et al. [17] showed that “prolactologists” carried out manual prolactination, which, to a certain extent, could improve the amount of lactation and the subjective well-being of mothers. However, “prolactologists” have not yet been listed in the occupational catalog of the national health and health administration. They lack authority in the breast milk care industry, normative job training systems, national certification standards, and professional and technical ability qualifications. Therefore, it was necessary to train professional breastfeeding consultants in the community and explore how to apply for a combination of hospital postpartum services and community door-to-door services, so that mothers can continue to receive guidance from breastfeeding professionals after returning home [18, 19, 20]. Good social and family support systems guarantee successful breastfeeding after discharge [13, 21]. In terms of nutrition and rest, family members should ensure that primiparas get a reasonable diet and proper rest. As for the emotional aspect, it was necessary to let primiparas feel the warmth of their family, avoid negative emotions that lead to breast swelling, and prevent the occurrence of mastitis.

4.6 Strengths and limitations

The strengths of the study are that it showed a lack of knowledge and curiosity about breastfeeding in some women, lack of access to correct breastfeeding knowledge, insufficient support from family members for postpartum breastfeeding, and lack of approach to solve problems during breastfeeding among primiparas. However, there are some limitations, such as small sample size, limited questions in the questionnaire, lack of a follow-up, which can be addressed in future studies.

5. Conclusion

Based on the above-mentioned problems in the current cognition of breastfeeding knowledge in primiparas, it was imperative to construct a set of health education models to help them improve their knowledge of breastfeeding during pregnancy.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Funding

The study was supported by the ‘Study on the Application of Health Education Model Based on IKAP Theory in Primipara Breastfeeding’ (No. 202014030468).

Ethics statement

The study was conducted with approval from the Ethics Committee of Hunan Provincial People’s Hospital (The First Affiliated Hospital of Hunan Normal University) (ethics approval number 2020-60). The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients before participating in the study.

Author contributions

LC W and L S conceived the idea and conceptualised the study. LW and BZ collected the data. FT, LW, LY, KQ and LY analysed the data. FT and LY obtained financing. FT drafted the manuscript. FT and XL reviewed the manuscript. All authors read and approved the final manuscript.

Footnotes

Acknowledgments

The authors would like to thank the hard and dedicated work of all staff that implemented the intervention and evaluation components of the study.

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Qualitative research on the cognition of breastfeeding knowledge in primiparas during pregnancy

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Material and methods

2.1 General material

2.2 Study methods

2.2.1 Literature research

2.2.2 Cross-sectional investigation

2.2.3 Collect and sort out data

3. Results

3.1 Lack of knowledge and curiosity about breastfeeding in some primiparas during pregnancy

Table 1 Composition of the interview sample

Table 2 Results of the five topics of the interview in ten primiparas during pregnancy

3.4 Lack of approached to solve problems during postpartum breastfeeding in primiparas

4. Discussion

4.1 Development of courses related to breastfeeding during pregnancy for primiparas

4.2 Conduction of health education on breastfeeding-related knowledge for primiparas as planned

4.2.1 The contents of breastfeeding knowledge education

4.2.2 The forms of breastfeeding knowledge education

4.3 Problem-solving-oriented breastfeeding clinics and internet consultations for case education and individualized guidance

4.4 Implementation of the “three early” of breastfeeding and seizing the key link to successful breastfeeding

4.5 Extending postpartum services and establishing good social and family support systems

4.6 Strengths and limitations

5. Conclusion

Competing interests

Availability of data and materials

Funding

Ethics statement

Author contributions

Footnotes

Acknowledgments

References

Table 1
Composition of the interview sample

Table 2
Results of the five topics of the interview in ten primiparas during pregnancy