Kathleen Kendall-Tackett, PhD, IBCLC, RLC, FAPA

A Swedish study shows the surprising ways that health care providers influence mothers’ breastfeeding experiences and how their attitude matters.

A fascinating study from Sweden shows that health care providers’ beliefs about breastfeeding influence mothers’ breastfeeding success, even when mothers are unaware of these attitudes (Ekstrom & Thorstensson, 2015). Providers may say all the right things, but what they actually believe creeps through. In this study, 585 mothers were randomly assigned to either intervention or control groups. In the intervention group, health care providers (midwives and child health nurses) were given Process-Oriented Training. Before training, they completed the Breastfeeding Attitude Scale, which measured four factors.

  1. The Regulating attitude focused on providers actively managing mothers’ breastfeeding experiences.
  2. The Facilitating attitude made it easy for mothers to manage their own breastfeeding.
  3. The Disempowering attitude included giving advice and disregarding the needs of the mother.
  4. The Breastfeeding Antipathy attitude included insufficient, basic breastfeeding knowledge and aversive reactions to breastfeeding.

The training was seven days of lectures that focused on participants’ breastfeeding experiences, their attitudes about breastfeeding, practical counseling skills, and collaborating and communicating with antenatal and child health centers. It included problem solving, self-reflection, and decision making. The training portion focused on evidence-based breastfeeding practices and how to provide parental support. In addition, this training included time for the practitioners to reflect on their own breastfeeding experiences, and what it was like for them to provide breastfeeding support. These sessions included individual reflection and group seminars with discussion.

The researchers made the following statement.

In order to improve attitudes, both fact and reflection are needed.

In other words, providers need to have accurate information and they need to get rid of their own junk regarding breastfeeding. If they had negative experiences, they were provided with opportunities to process those in order to provide good care. Providers in the control group provided usual care. Mothers were blinded to the treatment condition of their health care providers.

Outcomes included providers’ changes in attitude and the mothers’ experiences. The mothers were assessed at 3 days, 3 months, and 9 months. The mothers’ questionnaires assessed their experiences with professional and social support, their breastfeeding experiences, and their self-reported feelings about their babies.

One year after the intervention, providers in the intervention group had reduced their scores on the Regulating scale and increased their scores on the Facilitating scale. This improvement affected the mothers in several important ways.

Attitude Matters. Study Shows Surprising Ways to Influence Breastfeeding Experiences
Ken Tackett

Mothers’ perceptions of support

The mothers in the intervention group perceived the professional support that they received more positively. This support also created a halo effect that included people who were not in the original study. Mothers had more positive beliefs about support during their pregnancies if they had cesareans. Mothers also perceived more support from Labor & Delivery, even though the L&D staff members were not part of the intervention. In addition, they reported more help from other mothers.

Improved breastfeeding outcomes

The more interesting findings were the intervention’s effects on breastfeeding outcomes. Mothers in the intervention group reported better breastfeeding support. This translated into improved breastfeeding behaviors including earlier initiation, higher frequency during the first 24 hours, and less use of formula in the hospital and after discharge. After mothers left the hospital, they were more satisfied, and had fewer breastfeeding problems, such as insufficient milk, and longer breastfeeding duration. These mothers also reported more positive feelings about their babies than mothers in the control group.


It’s interesting to consider that this study took place in Sweden, a country with one of the highest breastfeeding rates in the world. Even there, some health care providers have incorrect information and negative attitudes towards breastfeeding. I believe this intervention would be much more powerful in the U.S.

In this country, we focus so much on educating mothers about breastfeeding, we sometimes forget how much providers bring to the table. As I describe in A Crisis in Confidence: Recent Study Finds More Pediatricians Believe Breastfeeding Will Fail, pediatricians are experiencing a crisis of confidence when it comes to breastfeeding. They say all the right things, but only slightly more than half believe that breastfeeding will work. We know that this lack of belief influences mothers in negative ways. How could it not? So many of our providers have had negative breastfeeding experiences and experienced terrible professional support. How realistic is it for us to then expect that they will provide excellent care when it was not modeled for them? Some of them do, but at what personal cost?

These findings suggest that if we are going to move the needle on our breastfeeding rates, we can’t just focus on education. Yes, we need to train providers on evidence-based practices. That’s important. But we also need to give them a chance to process and reflect on their own experiences. Providers who have had a chance to get rid of their junk are much more effective. Mothers feel supported, and their breastfeeding outcomes, at every time point, reflect this improved level of support.

Even if there are no large-scale interventions like this in your community, you can start small. Have a conversation with providers in your town and listen to their experiences. That’s an important step towards their healing. And if you had a negative experience, find someone you can share that with. We live in an imperfect world. All of us have junk from the past. Having someone to share it with will make you a better supporter and make the experience of providing lactation care more satisfying.

Thank you for all you do to provide care in an imperfect world. One by one, you are making a difference.


Ekström, A. C., & Thorstensson, S. (2015). Nurses and midwives professional support increases with improved attitudes – design and effects of a longitudinal randomized controlled process-oriented intervention. BMC Pregnancy and Childbirth, 15(1)275. doi:10.1186/s12884-015-0712-z

Kathleen Kendall-Tackett, PhD, IBCLC, FAPA

kathleen-kendall-tackett-womens-health-todayDr. Kendall-Tackett is a health psychologist and International Board Certified Lactation Consultant, and the owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. She is Editor-in-Chief of two peer-reviewed journals: Clinical Lactation and Psychological Trauma. She is Fellow of the American Psychological Association in Health and Trauma Psychology, Past President of the APA Division of Trauma Psychology, and a member of the Board for the Advancement of Psychology in the Public Interest.

Dr. Kendall-Tackett specializes in women’s-health research including breastfeeding, depression, trauma, and health psychology, and has won many awards for her work including the 2016 Outstanding Service to the Field of Trauma Psychology from the American Psychological Association’s Division 56. She has authored more than 400 articles or chapters, and recently completed her 35th book, The Phantom of the Opera: A Social History of the World’s Most Popular Musical. Her most recent books include: Depression in New Mothers, 3rd Edition (2016, Routledge UK, in press), Women’s Mental Health Across the Lifespan (2016, Routledge US, in press, with Lesia Ruglass), Psychology of Trauma 101 (2015, Springer, with Lesia Ruglass) and The Science of Mother-Infant Sleep (2014, Praeclarus, with Wendy Middlemiss). Her websites are UppityScienceChick.comBreastfeedingMadeSimple.comKathleenKendall-Tackett.com, and PraeclarusPress.com.

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