Perception of Omani Women of Exclusive Breastfeeding: a Grounded Theory Study

PERCEPTION OF OMANI WOMEN OF EXCLUSIVE BREASTFEEDING: A GROUNDED THEORY STUDY

A Thesis Submitted to The University of Manchester for the Degree of Doctor of Philosophy in the Faculty of Biology, Medicine, and Health

2020

ZALIKHA ALMARZOUQI

SCHOOL OF HEALTH SCIENCES

Division of Nursing, Midwifery and Social Work Table of Contents

LIST OF TABLES ...... 7 LIST OF FIGURES ...... 8 LIST OF BOXES ...... 9 LIST OF APPENDICES ...... 10 ABSTRACT ...... 12 DECLARATION STATEMENT ...... 13 COPYRIGHT STATEMENT ...... 13 ACKNOWLEDGEMENTS ...... 14 DEDICATION ...... 15 THE AUTHOR ...... 16 OUTLINE OF THE THESIS ...... 17 LIST OF ABBREVIATIONS ...... 18 BACKGROUND TO THE STUDY ...... 20 1.1 OVERVIEW ...... 20 1.2 HISTORY OF BREASTFEEDING ...... 20 1.3 INTRODUCTION OF ARTIFICIAL MILK ...... 22 1.4 WHO RECOMMENDATIONS FOR INFANT FEEDING ...... 23 1.5 HEALTH BENEFITS OF BREASTFEEDING ...... 25 1.5.1 Health benefits of breastfeeding for infants ...... 25 1.5.2 Health benefits of breastfeeding for women ...... 27 1.5.3 Psychological benefits of breastfeeding ...... 27 1.6 DEFINITIONS OF BREASTFEEDING ...... 28 1.6.1 Definition of breastfeeding within the Omani context ...... 29 1.7 BREASTFEEDING POLICIES ...... 29 1.8 EXCLUSIVE BREASTFEEDING RATE ACROSS THE WORLD ...... 30 1.8.1 Exclusive breastfeeding rate in high-income countries ...... 30 1.8.2 Exclusive breastfeeding rate in low-and middle-income countries ...... 31 1.8.3 Exclusive breastfeeding rate in Gulf Cooperation Council Countries ...... 31 1.8.4 Factors affecting breastfeeding...... 32 1.9 STUDY CONTEXT: THE SULTANATE OF OMAN ...... 32 1.9.1 Geography ...... 32 1.9.2 Demographic profile ...... 34 1.9.3 Development in Oman ...... 35 1.9.4 Women’s status in Oman ...... 35 1.9.5 Family structure in Oman ...... 38 1.9.6 Breastfeeding in Islam ...... 39 1.9.7 Breastfeeding within the social context in Oman ...... 40 1.10 HEALTHCARE SYSTEM IN OMAN ...... 41

2 1.10.1 Maternal and child health services in Oman ...... 43 1.10.2 Baby-Friendly Hospital Initiative ...... 44 1.11 DETERMINANTS OF BREASTFEEDING ...... 46 1.12 RATIONALE FOR THE STUDY ...... 47 1.13 SUMMARY ...... 47 LITERATURE REVIEW ...... 50 2.1 OVERVIEW ...... 50 2.2 POSITIONING OF THE LITERATURE REVIEW IN A GROUNDED THEORY STUDY ...... 50 2.3 RATIONALE FOR SELECTING A NARRATIVE REVIEW ...... 52 2.4 AIM OF THE REVIEW ...... 53 2.5 QUESTION RELATED TO THE REVIEW ...... 53 2.6 SEARCH STRATEGY ...... 54 2.7 QUALITY ASSESSMENT OF THE SELECTED STUDIES ...... 57 2.8 FINDINGS FROM THE SEARCH ...... 58 2.9 DESCRIPTION OF THE SYNTHESISED QUALITATIVE STUDIES ...... 60 2.10 ANALYSIS AND SYNTHESIS OF THE NARRATIVE REVIEW FINDINGS ...... 62 2.10.1 Breastfeeding motivators ...... 64 2.10.2 Social support for breastfeeding ...... 67 2.10.3 Breastfeeding experiences ...... 70 2.10.4 Persistence ...... 75 2.11 SUMMARY OF THE LITERATURE REVIEW FINDINGS ...... 76 2.12 STRENGTHS AND LIMITATIONS OF THE REVIEW ...... 77 2.13 CONCLUSION ...... 78 METHODOLOGY AND METHODS ...... 81 3.1 OVERVIEW ...... 81 3.2 STUDY AIMS AND OBJECTIVES...... 81 3.2.1 Study aims ...... 81 3.2.2 Study objectives ...... 81 3.3 PHILOSOPHICAL UNDERPINNINGS OF RESEARCH...... 81 3.4 STUDY PARADIGMS ...... 82 3.5 UNDERPINNING ASSUMPTIONS ...... 85 3.6 THEORETICAL PERSPECTIVE: SYMBOLIC INTERACTIONISM ...... 86 3.7 STUDY DESIGN ...... 88 3.8 GROUNDED THEORY METHODOLOGY ...... 90 3.8.1 Overview of grounded theory ...... 91 3.8.2 Selecting constructivist grounded theory ...... 93 3.9 RESEARCH METHODS ...... 95 3.9.1 Selecting the study sites ...... 95 3.9.2 Sampling ...... 96

3 3.9.3 Sample size...... 98 3.10 DATA COLLECTION METHODS ...... 99 3.10.1 Semi-structured interviews ...... 99 3.10.2 Topic guide ...... 102 3.10.3 Data collection process ...... 102 3.10.4 Transcription process ...... 104 3.10.5 Translation process ...... 105 3.10.6 Non-participant observations ...... 106 3.11 DATA ANALYSIS IN CONSTRUCTIVIST GROUNDED THEORY ...... 109 3.11.1 Initial coding ...... 110 3.11.2 Focused coding ...... 112 3.11.3 Theoretical coding ...... 114 3.12 THEORETICAL SENSITIVITY...... 114 3.13 MEMO-WRITING ...... 116 3.14 THEORETICAL SATURATION ...... 118 3.15 DATA MANAGEMENT ...... 119 3.16 ETHICAL CONSIDERATIONS ...... 120 3.16.1 Informed consent and voluntary participation ...... 120 3.16.2 Autonomy ...... 121 3.16.3 Confidentiality and data storage ...... 122 3.16.4 Lone working ...... 123 3.17 SUMMARY ...... 124 INTRODUCTION TO THE RESEARCH FINDINGS ...... 126 4.1 OVERVIEW ...... 126 4.2 STUDY SAMPLE CHARACTERISTICS ...... 126 4.2.1 Access to and recruitment of research participants ...... 127 4.2.2 Total participants in this study...... 137 4.2.3 Socio-demographic information of the postnatal women ...... 137 4.2.4 Socio-demographic information of the family members ...... 145 4.2.5 Socio-demographic information of the healthcare professionals ...... 145 4.3 PRESENTING THE FINDINGS ...... 151 BREASTFEEDING EXPECTATIONS ...... 155 5.1 OVERVIEW ...... 155 5.2 ‘I KNEW THAT I WOULD BREASTFEED’ ...... 155 5.2.1 Social norms within the Omani context ...... 155 5.2.2 Islamic guidelines on breastfeeding ...... 158 5.2.3 Benefits of breastfeeding ...... 160 5.3 ‘IT IS A NATURAL PROCESS’ ...... 162 5.3.1 ‘Natural food for the baby’ ...... 164 5.4 EXPECTING SUPPORT ...... 165

4 5.5 LACKING PREPAREDNESS FOR BREASTFEEDING ...... 166 5.6 SUMMARY...... 171 BREASTFEEDING SUPPORT ...... 174 6.1 OVERVIEW ...... 174 6.2 FAMILY MEMBERS’ PRESENCE...... 174 6.3 LACK OF HEALTHCARE PROFESSIONALS’ SUPPORT...... 179 6.4 SUMMARY...... 189 BREASTFEEDING JOURNEY ...... 192 7.1 OVERVIEW ...... 192 7.2 EARLY BREASTFEEDING EXPERIENCES...... 192 7.3 WOMEN’S ABILITY TO BREASTFEED ...... 200 7.3.1 Conflicting needs ...... 200 7.3.2 Work commitments ...... 202 7.3.3 Physical discomfort ...... 202 7.3.4 Perceptions of insufficient milk production ...... 203 7.3.5 Breastfeeding in public ...... 205 7.3.6 Dealing with social role expectations ...... 209 7.4 FACTORS IN SUCCESSFUL BREASTFEEDING ...... 213 7.5 SUMMARY...... 214 SYNTHESIS AND DISCUSSION ...... 217 8.1 OVERVIEW ...... 217 8.2 CORE CATEGORY: NAVIGATING THE REALITY OF BREASTFEEDING ...... 217 8.3 BREASTFEEDING INTENTION ...... 223 8.3.1 Sociocultural construct of the intention to breastfeed ...... 223 8.3.2 Being expected to breastfeed ...... 226 8.4 WOMEN’S ABILITY TO BREASTFEED ...... 227 8.4.1 Mismatch between the reality of breastfeeding and women’s expectations ...... 228 8.4.2 Lack of social support ...... 229 8.4.3 System lacking the practical component of breastfeeding ...... 239 8.4.4 Lack of knowledge of managing breastfeeding difficulties ...... 241 8.5 THEORETICAL MODEL: RESILIENCE: THE POWER TO BREASTFEED ...... 243 8.6 CONCLUSION ...... 249 CONCLUSIONS AND RECOMMENDATIONS ...... 252 9.1 OVERVIEW ...... 252 9.2 CONCLUSION OF THE STUDY ...... 252 9.3 RIGOUR OF THE RESEARCH STUDY ...... 253 9.3.1 Credibility ...... 253 9.3.2 Originality ...... 255 9.3.3 Resonance ...... 257

5 9.3.4 Usefulness ...... 257 9.4 REFLEXIVITY ...... 258 9.5 STRENGTHS AND LIMITATIONS OF THE RESEARCH STUDY ...... 260 9.5.1 Strengths ...... 260 9.5.2 Limitations ...... 261 9.6 RECOMMENDATIONS FOR PRACTICE, POLICY, EDUCATION AND FUTURE RESEARCH ...... 263 9.6.1 Practice...... 263 9.6.2 Policy ...... 265 9.6.3 Education ...... 265 9.6.4 Future research ...... 266 9.7 IN CLOSING ...... 266 REFERENCES...... 268 APPENDICES ...... 305

Word count: 81,785 words (excluding references and appendices)

6 List of Tables

Table 1.1: WHO definitions of breastfeeding ...... 29 Table 2.1: Key concepts in the review question and its search terms ...... 55 Table 2.2: Inclusion and exclusion criteria for the literature review ...... 56 Table 2.3: Qualitative studies included in the review ...... 61 Table 2.4: Themes identified from the narrative review ...... 63 Table 3.1: Inclusion criteria for the participants of the study ...... 97 Table 3.2: Example of initial coding ...... 112 Table 3.3: Example of focused coding ...... 113 Table 4.1: Total numbers of participants in this study ...... 137 Table 4.2: Socio-demographic information of the postnatal women (interviews) ...... 139 Table 4.3: Socio-demographic information of the postnatal women (clinical observations) ...... 142 Table 4.4: Socio-demographic information of the healthcare professionals...... 146 Table 4.5: Socio-demographic information of the maternity unit managers ...... 147 Table 4.6: Socio-demographic information of the healthcare professionals (observations) ...... 149 Table 4.7: Categories and sub-categories of the research findings ...... 152

7 List of Figures

Figure 1.1: Map of the Sultanate of Oman ...... 33 Figure 1.2: Population pyramid for the Sultanate of Oman ...... 34 Figure 1.3: Exclusive breastfeeding rate in 2013 ...... 45 Figure 1.4: Exclusive breastfeeding and artificial feeding rates in 2016 ...... 45 Figure 2.1: Flow diagram of the literature search strategy ...... 59 Figure 4.1: Flow diagram showing access to and recruitment of postnatal women ..... 129 Figure 4.2: Flow diagram showing access to and recruitment of family members for interviews ...... 131 Figure 4.3: Flow diagram showing access to and recruitment of healthcare professionals (HCP) for interviews ...... 133 Figure 4.4: Flow diagram showing access to and recruitment of research participants for the clinical observations ...... 136 Figure 7.1: Factors in successful breastfeeding ...... 214 Figure 8.1: Development of the core category from the three main categories ...... 219 Figure 8.2: The emergent theory ...... 249

8 List of Boxes

Box 1.1: Ten steps to successful breastfeeding ...... 24 Box 3.1: Memos interpreting data on breastfeeding support within the Omani context ...... 118

9 List of Appendices

Appendix 1: Hawker’s Assessment Tool ...... 305 Appendix 2: Assessing Studies Using Hawker’s Appraisal Tool ...... 309 Appendix 3: Summary and Characteristics of the Studies Included ...... 312 Appendix 4: Sample of Interview ...... 358 Appendix 5: Timing of interviews and Breastfeeding Cessation ...... 370 Appendix 6: Topic Guide for Postnatal Mother Interview ...... 371 Appendix 7: Topic Guide for Postnatal Mother Interview (Update) ...... 372 Appendix 8: Topic Guide for Family members of Women’s Participants ...... 374 Appendix 9: Topic Guide for Healthcare Professionals Interview ...... 376 Appendix 10: Sample of the Clinical Observation ...... 378 Appendix 11: Observation Guide ...... 386 Appendix 12: Observation Sheet (Update) ...... 388 Appendix 13: Example of Initial Coding with NVivo ...... 391 Appendix 14: Ethical Approval Research Ethics Committee at the UOM ...... 392 Appendix 15: Ethical Approval Research Ethics Committee in the MOH in Oman ... 393 Appendix 16: Postnatal Mother Advertisement Interview (English and Arabic) ...... 394 Appendix 17: Postnatal Mother Advertisement Observation (English and Arabic) .... 395 Appendix 18: PIS for Postnatal Mother/ Interview (Arabic) ...... 396 Appendix 19: PIS for Family Members/ Interview (Arabic) ...... 398 Appendix 20: PIS for Postnatal Mothers Observation (Arabic)...... 400 Appendix 21: Consent Form for Postnatal Mother/ Interview (Arabic) ...... 402 Appendix 22: Consent Form for Family Members/ Interview (Arabic) ...... 403 Appendix 23: Consent Form for Postnatal Mother/ Observation (Arabic) ...... 404 Appendix 24: Distress Policy ...... 405 Appendix 25: Lone Working Policy ...... 406 Appendix 26: Orientation Workshop Outline with the Gatekeepers ...... 407 Appendix 27: PIS for Postnatal Mothers Interview (English) ...... 408 Appendix 28: Consent to Contact Form (English Version) ...... 412 Appendix 29: Consent to Contact Form (Arabic Version) ...... 413 Appendix 30: Consent Form for Postnatal Mothers Interview (English) ...... 414 Appendix 31: Demographic Data for Postnatal Mothers ...... 415 Appendix 32: PIS for Family members Interview (English) ...... 417

10 Appendix 33: Consent Form Family Members (English) ...... 420 Appendix 34: Poster Advertisement for Healthcare Professionals (Interview) ...... 421 Appendix 35: PIS for Healthcare Professionals Interview (English) ...... 422 Appendix 36: Consent Form for Healthcare Professionals Interview (English) ...... 425 Appendix 37: PIS for Postnatal Mothers / Observation (English) ...... 426 Appendix 38: Consent Form for Postnatal Mothers/ Observation (English) ...... 429 Appendix 39: Healthcare Professionals Leaflet (Clinical Observation) ...... 430 Appendix 40: PIS for Healthcare Professionals Observation (English) ...... 431 Appendix 41: Consent Form for Healthcare Professionals/ Observation (English) ..... 434 Appendix 42: Breastfeeding Policy in Oman ...... 435 Appendix 43: Criteria for Evaluating the Rigour of the Study ...... 436

11 Abstract

The University of Manchester

ABSTRACT OF THESIS submitted by Zalikha Al-Marzouqi for the degree of Doctor of Philosophy and entitled: Perception of Omani women of exclusive breastfeeding: a grounded theory study.

Background and Aim: According to the Ministry of Health (MOH) in Oman, 92.1% of women initiate exclusive breastfeeding at birth but this rate reduces sharply to 10.2% when the baby reaches six months of age (MOH, 2016). This decline in breastfeeding suggests a need to explore the breastfeeding experience of Omani women. The aim of this study was to explore women’s experiences of exclusive breastfeeding in Oman.

Methodology and Methods: An exploratory qualitative design, informed by constructivist grounded theory principles. This study included 11 postnatal women, 5 family members of the same women participants and 7 healthcare professionals. Initially, five women were recruited through purposive sampling and participated in semi- structured interviews. In total, 69 semi-structured interviews and 15 observations were used for all participants in this study. Theoretical sampling was applied when categories appeared during the analysis of the data. A constructivist grounded theory analytical structure of initial, focused and theoretical coding was undertaken to analyse the data gathered.

Findings and Discussion: The core category, ‘Navigating the Reality of Breastfeeding’ developed from the three main categories; namely, breastfeeding expectations, breastfeeding support and breastfeeding journey. The core category reflects the concept of women undertaking the process of breastfeeding with uncertainty because they did not know how to deal with breastfeeding difficulties. The women in the study did not know what to expect when breastfeeding. Navigating the unknowns with uncertainty feeling made the women’s experience with breastfeeding difficult. Women recognised that they had unrealistic expectations, lacked the practical components of breastfeeding, did not have theoretical knowledge of breastfeeding challenges and their management and very little support. These unknowns regarding the reality of breastfeeding made the women feel confused, upset, frustrated, disappointed and stressed, which led them to stop breastfeeding. However, three women were able to breastfeed. The core category was central to the emergent theory: ‘Resilience: The Power to Breastfeed’. The Theory suggests that women’s ability to breastfeed depended on their resilience. The three women continued breastfeeding by using adaptive and problem-solving strategies, gaining knowledge quickly, and learning from their difficulties and experiences. The three women continued breastfeeding until the end of the data collection period (which lasted four months).

Conclusion: The findings of this study demonstrated that women’s ability to breastfeed depends on their resilience in adapting to breastfeeding difficulties. This study aids understanding of the social processes involved in exclusive breastfeeding. The findings could help in informing plans or programmes for improving the breastfeeding rate in Oman.

12 Declaration Statement

No portion of the work referred to in this thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning.

I. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “copyright”) and she has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. II. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. III. The ownership of certain Copyright, patents, designs, trademarks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. IV. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=24420), in any relevant Thesis restriction declarations deposited in the University Library, The University Library‘s regulations (see http://www.library.manchester.ac.uk/about/regulations/) and in The University‘s policy on Presentation of Theses.

13 Acknowledgements

In the name of Allah, the Most Courteous and the Most Merciful, all appreciation to Allah for the health and His commendation in giving me the strength and pliability without which I would not be capable of achieving this thesis.

Exceptional thanks and appreciation go to my supervisors, Professor Dame Tina Lavender, Dr Rebecca Smyth and Dr Carol Bedwell, for their supervision. I am grateful to all of them for their continuous support and for providing valuable and constructive comments during my PhD journey.

I would also like to express my appreciation for the role of the Ministry of Health in Oman for funding and supporting me for three years in this four-year PhD journey and for approving the conduct of the study in the healthcare institutions. To all the maternity unit managers, midwives, and nurses, I appreciate your help and support during the data collection process and for taking part in my research. I express my thankfulness to all the women and their families for their precious contributions and information in this research.

My heartfelt, sincere thanks and honour go to my beloved husband, Said Al-Shibli, and my children, Mohammed, Al-Yaziya, Retaj and Renad, who were outstanding in tolerating me and providing love, care and support during my PhD journey. My sincerest thanks also go to my beloved mother, sister and brothers and friends, especially Samira and Aliya, for their endless love, prayers and encouragement.

Last but not least, I would like to thank all who contributed to this research: your kindness made this PhD journey successful and meant a lot to me. Thank you so much.

14 Dedication

I dedicate this research project to my beloved husband, son and daughters, and to my mother, for their exceptional caring, love and encouragement. May Allah bless you all.

I also dedicate this research project to women in the Gulf region generally and especially in Oman and I hope to promote their experience of breastfeeding.

15 The Author

I am a nursing lecturer at Oman College of Health Sciences, North Batinah Branch, one of the Ministry of Health’s (MOH) nursing educational institutions in the Sultanate of Oman. I have taught on the maternal and child health nursing and community health nursing curriculum since 2003. I graduated from North Batinah Nursing Institute in 1999 with a diploma in nursing. In 2002, I completed my BSc in nursing at Villanova University in the United States of America. I obtained an MSc in professional practice at the University of Central Lancashire in the UK in 2007. My interest in breastfeeding developed during my clinical observations when I was teaching my students in maternity units. I had observed in the MOH records that the breastfeeding rate reduces after birth and that most of the women stopped breastfeeding within six months of giving birth. My interest also came from my personal experience of breastfeeding as a mother. I thought that I had stopped breastfeeding due to my work. However, I also observed that women who were not working stopped breastfeeding within six months of giving birth, so I was interested to learn the reason for breastfeeding cessation and what influenced women to continue breastfeeding.

I have presented this study at conferences and showcases in the UK (University of Manchester and Liverpool John Moores University) and Oman (OmaniExpo exhibition). I also attended a two-day workshop on constructivist grounded theory provided by Kathy Charmaz in July 2018 at Lancaster University. The workshop increased my confidence; especially in analysis, which was the stage I had reached at the time.

16 Outline of the Thesis

This study is presented in nine chapters, as follows.

Chapter one provides background information about breastfeeding. In addition, it addresses the contexts of the study setting and outlines the purpose of the study.

Chapter two describes the study through a literature review of the available research studies. The review focuses on primary studies that relate to women’s experiences of breastfeeding across different socioeconomic countries.

Chapter three presents the aims and objectives, the methodology and methods of the study, as well as the theoretical and methodological perspective that underpinned the research. An outline of the research process provides an in-depth discussion of the methods and processes used for accessing and recruiting the participants of the study. The chapter also details the methods of data generation and analysis.

Chapters four to seven present the three main emergent categories from which the emerged core category and theory are composed.

Chapter eight provides the development of the core category, it also includes synthesis and discussion of the research findings, and the emerged grounded theory.

Chapter nine presents the summary of the study. It also details the originality, resonance and usefulness of the findings, the strengths and limitations of the study and recommendations for practice, policy, education and future research.

17 List of Abbreviations

Abbreviations Full term AAP American Academy of Paediatrics ARI Acute respiratory infection BFHI Baby-Friendly Hospital Initiative CABG Coronary artery bypass grafting CASP Critical Appraisal Skills Programme CDC Centers for Disease Control and Prevention CINAHL Cumulative Index to Nursing and Allied Health Literature CSGVs Community Support Group Volunteers EBF Exclusive breastfeeding GCC Gulf Cooperation Council GPI Global Peace Index IBFAN International Baby Food Action Network IGAB Interagency Group for Action on Breastfeeding KSA Kingdom of Saudi Arabia LR Labour room MEDLINE Medical Literature Analysis and Retrieval System Online MOH Ministry of Health (Sultanate of Oman) MCH Maternal and Child Health MG Multigravida NBG North Batinah Governorate NCSI National Centre for Statistics and Information (Sultanate of Oman) NICU Neonatal intensive care unit ORS Oral rehydration solution PEM Protein energy malnutrition PHC Primary health care PICO Population, Intervention, Comparison and Outcomes PNW Postnatal ward PNC Postnatal clinics PG Primigravida PIS Participant information sheet RERAC Research and Ethical Review and Approve Committee RCPCH Royal College of Paediatrics and Child Health UAE United Arab Emirates UNICEF United Nations International Children’s Emergency Fund UNFPA United Nations Population Fund UREC UOM Research Ethics Committee UOM University of Manchester WHO World Health Organization

Chapter One: Background to the Study

19 Background to the Study

1.1 Overview

The World Health Organization (WHO) advises mothers all over the world to breastfeed their infants exclusively for the first six months after birth to gain optimal development and health. After that, infants should be provided with complementary foods and continue breastfeeding up to two years or beyond (WHO, 2011). Despite the implementation of the Baby-Friendly Hospital Initiative (BFHI) in 1992, Oman has struggled to maintain high levels of Exclusive Breastfeeding (EBF). According to annual health reports issued by the Ministry of Health (MOH) in Oman, the rate of EBF reduces considerably, particularly when babies reach six months of age. For example, in 2016, 92.1% of women initiated breastfeeding at the hospital, and only 10.2% of women exclusively breastfeed their babies at six months (MOH, 2016). Thus, it is essential to explore women’s breastfeeding experience and understand their perceptions concerning breastfeeding in Oman.

This chapter presents the background to this research study. It begins by offering an overview of the history of breastfeeding and the impact of artificial milk. The chapter illustrates the recommendations on infant feeding given by the World Health Organization and outlines the scientific evidence relating to the health benefits of breastfeeding for both women and their babies (WHO, 2003). The chapter also highlights definitions of breastfeeding and breastfeeding policies. Rates of breastfeeding in high- and low-income countries are also explained in this chapter. Finally, the chapter provides an overview of the study context of Oman, with emphasis on the healthcare system with regard to maternal and child health services. The rationale for the study and a summary of the work are presented at the end of the chapter.

1.2 History of Breastfeeding

Breastfeeding is considered to be the primary source of food for infants since humans were first present on the Earth and various communities have honoured breast milk since ancient times due to its importance (Macadam and Dettwyler, 1995). Breastfeeding is a natural method of feeding a baby and women in different communities breastfeed their babies because it is the most accessible and cost-effective way of feeding an infant (Sellen, 2009). Artists have also portrayed women suckling infants in many creative

20 works, such as drawings and sculptures, reflecting the importance of lactation for human sustenance and survival (Sellen, 2009). This also reflects the value placed on breastfeeding since ancient times. Breastfeeding is not only considered to be a biological process for women and their babies, but also a culturally determined behaviour (Wells, 2006). It is seen as a common practice among women in various communities and as a social practice that is performed by women in all cultures all over the world (Macadam and Dettwyler, 1995).

Ancient scriptures from different religions refer to the importance of breastfeeding for mothers and their babies. For example, the Vedas, which are ancient Indian scriptures, illustrate the value of breastfeeding for both breastfeeding mothers and their babies and consider breast milk to have active power for an infant’s health (Papastavrou et al., 2015). According to Indian scripture, breastfeeding should last until the eruption of the infant’s teeth, and should be given to a baby for the first six months of life (Papastavrou et al., 2015). The Ancient Egyptians also acknowledged the importance of breastfeeding for their infants. For instance, there is a drawing on one wall in a pyramid that depicts the goddess Isis breastfeeding her son Horus, representing the importance of breast milk in the Ancient Egyptian culture (Papastavrou et al., 2015). In Ancient Egyptian society, in cases in which mothers were not able to breastfeed their babies, wet nurses were the alternative and would breastfeed and take care of, amongst others, the Pharaoh’s infants (Papastavrou et al., 2015). A wet nurse is a woman who breastfeeds and cares for babies that are not her own (Hacker, 1828). Religious scripture, including the Holy Quran, also recommends breastfeeding practices and advises women to breastfeed for two years. The Holy Quran stipulates that

The mothers shall give suck to their children for two whole years, that is for those parents who desire to complete the term of suckling…and if you decide on a foster suckling-mother, there is no sin on you, provided you pay the mother what you agreed on a reasonable basis (Surat Al-Baqarah, 2:233).

Until the nineteenth century, breastfeeding was the standard in high-income countries and all infants were breastfed by their mother (Papastavrou et al., 2015). If mothers were not able to breastfeed due to sickness, or death, the responsibility for breastfeeding was taken over by other women who had recently delivered an infant. Over time, these women came to be named ‘wet nurses’ and were available for breastfeeding services, especially to rich people (Sussman, 1977). Wet nurses also breastfed infants in Arab countries before the arrival of Islam. Infants who were breastfed by wet nurses were known as milk-siblings

21 and children who had been breastfed by wet nurses were regarded as siblings to the wet nurse’s other children. Wet nursing services provided some help when mothers were ill and, later, when women went out to work, wet nursing services became a business and wet nurses earned money for feeding infants (Stevens et al., 2009). In Europe, wet nursing continued until the nineteenth century, although many people had come to refuse those services by the early seventeenth century (Sussman, 1977). Their reason for rejecting wet nursing services was the high mortality rate of infants in the first year of life at that time (Fass, 2004). Women were then obliged by law to breastfeed their babies (Schiebinger, 1995). In the nineteenth century, the Industrial Revolution led to the majority of people living in urban areas in order to find work and women also worked outside the home to help their family, which led to women’s selection of artificial feeding methods (Papastavrou et al., 2015).

1.3 Introduction of Artificial Milk

The German chemist Justus Von Liebig studied the chemistry of food and created the first breast milk substitute in the nineteenth century (Radbill, 1981). This food consisted of malt flour, wheat flour and cow’s milk cooked with a small amount of potassium bicarbonate (Radbill, 1981). Another German scientist, Henri Nestlé, invented farine lactée (wheat flour with milk) in Switzerland in 1843, a product that became popular for feeding infants (Radbill, 1981). Many women accepted artificial food for their infants because of advertisements and medical professionals’ encouragement (Palmer, 1988). Women in wealthy families also started giving artificial milk to their infants and this practice spread to poor women who were working outside the home (Stevens et al., 2009). As a result, many of the women at that time reported having insufficient milk syndrome, and they stop breastfeeding (Greiner et al., 1981). It is important to note that the introduction of artificial milk weakened the status of breastfeeding and, as the twentieth century progressed, breastfeeding rates dropped in Europe and North America because of the innovation. In Western countries, breastfeeding rates decreased from the late 1800s to the 1960s (Riordan and Countryman, 1980). People’s attitude to breastfeeding was that it was practised by the illiterate and the lower classes. People considered those who could not give their baby artificial feeding and practised breastfeeding to be old-fashioned (Nathoo and Ostry, 2009). However, after the mid-1960s, there was a revival in

22 breastfeeding practice among the more educated and wealthy women in the USA and Canada (Nathoo and Ostry, 2009).

Before the move to develop Oman in 1970, all Omani women breastfed their baby’s exclusively because they did not have an alternative (i.e., artificial milk) (Al Sinani, 2008). Breast milk was the only source of food for infants in Oman and women were exclusively breastfeeding until introducing complementary foods; they then continued breastfeeding and giving complementary foods until the child was two years of age or older (Al Sinani, 2008). Omani women did not work outside the home before 1970 and thus breastfed their baby for two or more years (Al Sinani, 2008). After 1970, with the development of the country, artificial milk was exported to Oman and different companies marketed artificial milk within government hospitals and on television (Al Sinani, 2008). Omani women also started working outside the home and many of them, especially those with jobs, preferred to use artificial milk (Al Sinani, 2008).

1.4 WHO Recommendations for Infant Feeding

The WHO encourages EBF for at least six months after childbirth, with continued breastfeeding concurrent with complementary food until two years of age or older (WHO, 2011). According to the WHO, EBF means that babies should not receive food or drink, not even water, other than breast milk for the first six months of the child’s life, but they are allowed to receive drops and syrups, such as vitamins, minerals and medication (WHO, 2019). Initiation and then continuation of breastfeeding are considered to be indicators of the best practice of breastfeeding (WHO, 2011). Thus, the WHO implements global guidelines for infant feeding, such as the BFHI (WHO, 2011). The BFHI is a global programme of the WHO and the United Nations International Children’s Emergency Fund (UNICEF) and started in 1991 (UNICEF, 2014). The initiative has grown in more than 156 countries around the world (WHO, 2018). The BFHI is an international effort to improve maternity services to enable and support breastfeeding women to breastfeed their babies exclusively by implementing ten steps of successful breastfeeding (WHO, 2018). The ten steps of successful breastfeeding compile a set of policies that health facilities giving maternity and baby services should perform to support breastfeeding (WHO, 2018). WHO encouraged all health facilities offering maternity and baby services all over the world to implement the ten steps of successful breastfeeding (WHO, 2018). The ten steps to successful breastfeeding are illustrated in Box 1.1.

The Ten Steps to Successful Breastfeeding are:

1. Have a written breastfeeding policy that is routinely communicated to

all healthcare staff. 2. Train all healthcare staff in the skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of

breastfeeding.

4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even

if they are separated from their infants. 6. Give infants no food or drink other than breast milk, unless medically

indicated. 7. Practise rooming in – allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand.

9. Give no pacifiers or artificial nipples to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth centre.

Box 1.1: Ten steps to successful breastfeeding (Source: WHO, 2012)

The WHO promotes breastfeeding practice at healthcare institutions by informing pregnant and postnatal women of the health benefits of breastfeeding for them and their babies (WHO, 2018). It also encourages the early initiation of breastfeeding, which should be done within the first hour after the birth (WHO, 2019). The WHO intends to increase efforts to support appropriate infant feeding globally (WHO, 2019) and aims to reach a 50% universal rate of EBF by the year 2025 (WHO, 2012). The health benefits of breastfeeding are such that the WHO encourages governments all over the world to

24 improve and implement infant feeding policies and to allow breastfeeding women to receive enough support to initiate and continue EBF for at least six months (WHO, 2009). Furthermore, the WHO trains healthcare professionals in breastfeeding counselling and promotes the application of BFHI guidelines in healthcare institutions (WHO, 2009). However, despite international attempts to promote breastfeeding practice, the rate of EBF is low in both high- and low-income countries. For example, according to a statistical review conducted by UNICEF, only 41% of babies were breastfed exclusively for six months of life in low-income countries (UNICEF, 2018). This picture indicates either that the women in those countries are unaware of the importance of EBF or that they do not want to follow the breastfeeding advice given by the WHO. It may also be the case that women do not receive health education regarding breastfeeding from their healthcare professionals. Accordingly, it is essential to understand the reasons for the underachievement of WHO breastfeeding recommendations at the global level.

1.5 Health Benefits of Breastfeeding

1.5.1 Health benefits of breastfeeding for infants According to the WHO, EBF could protect around two million children yearly (WHO, 2011). Over the past decades, breastfeeding has been recognised as being the healthiest type of food for infants; thus, attention has been given to promoting breastfeeding practices all over the world (Butte et al., 2002). According to the American Academy of Paediatrics (AAP), breastfeeding improves infants’ physical health (Eidelman and Schanler, 2012). Breastfeeding is supported by an increasing amount of scientific evidence of its importance in reducing mortality rates among new-borns (Turck, 2005; Edmond et al., 2006; Brülde, 2011). Breast milk has been recognised as a powerful way to achieve these goals because of its health benefits. Breast milk is easy to digest, has a low solute load and has a number of vitamins, minerals and proteins vital for the health of infants (Arora et al., 2000; Turck, 2005; Kramer and Kakuma, 2007).

Breastfeeding is also a suitable way through which babies are given the nutrients essential to their physical and intellectual growth and development (Lawrence, 1994; Dewey et al., 1995; Turck, 2005; Kramer and Kakuma, 2007). In a study by Vennemann et al. (2009), breastfeeding was reported to protect infants against sudden infant death syndrome and to reduce the risk by 50% at all ages during childhood.

25 The health benefits of breastfeeding have been reported to show a relationship between the dose and response of breastfeeding (Vennemann et al., 2009), meaning that the health of infants increases when prolonging the duration of breastfeeding. The current evidence is that breastfed infants have better physical growth and development compared with infants who received bottle feeding (Kramer and Kakuma, 2007).

Breastfed infants have a reduced risk of experiencing a number of illnesses due to the unique immune-protective features that are possessed by breast milk (Prameela and Vijaya, 2012). For example, when infants breastfeed for the first six months of their lives, they are protected against significant childhood diseases, such as diarrhoea, gastrointestinal tract infection, allergic diseases, diabetes, obesity, childhood leukaemia and lymphoma, and inflammatory and bowel disease (Dewey et al., 1995; Bhandari et al., 2003; Allen and Hector, 2005; Turck, 2005; Eidelman and Schanler, 2012). In addition, infants’ hospitalisation during the first year of life due to lower respiratory tract infections is reduced by 72% when they are breastfed for more than four months (Ip et al., 2009). It has also been found that breastfeeding protects infants from otitis media and that infants who receive foods before four months have 40% more incidence of otitis media than those who received breast milk only (Duncan et al., 1993). Moreover, Horta et al. (2007) evaluated evidence of the long-term health benefits of breastfeeding in high-income countries and reported that breastfed infants were less likely to have high blood pressure and total cholesterol levels later in life. Breastfed children have also demonstrated higher performance in intelligence tests compared with bottle-fed children (Horta et al., 2007). Another research study showed that breastfed infants had fewer atopic skin diseases (Wright et al., 1989). Thus, breastfeeding is acknowledged to be the most important form of food for infants’ health.

Furthermore, artificial feeding is unsafe in some areas of the world, such as sub-Saharan African countries in Africa, due to contaminated water (UNICEF, 2015). For the people in those countries, it is not easy to guarantee that water sources are safe (UNICEF, 2015). With artificial feeding, water is needed to dissolve the milk powder and, if the water is contaminated, this may cause diseases such as diarrhoea for the infants who drink it, which can be fatal for them (UNICEF, 2015). Thus, exclusive breastfeeding is important for infants’ health in these countries.

26 1.5.2 Health benefits of breastfeeding for women Breastfeeding is not only essential to the growth and development of babies, but also for the health of women who breastfeed their babies (Macadam and Dettwyler, 1995; Blincoe, 2005; Godfrey and Lawrence, 2010). Many research studies have shown the short- and long-term influences of breastfeeding on the health of mothers who breastfeed their babies (Leon-Cava et al., 2002; Allen and Hector, 2005; Blincoe, 2005; Godfrey and Lawrence, 2010). For the short-term effects, it is well known that women who breastfeed their babies recover from childbirth quickly. Early initiation of breastfeeding decreases the risk of postpartum haemorrhage (Leon-Cava et al., 2002; Blincoe, 2005). It has also been identified that breastfeeding helps the early return of the uterus to its pre-pregnancy position and its normal size by the production of the hormone oxytocin (Leon-Cava et al., 2002; Blincoe, 2005; Godfrey and Lawrence, 2010).

For the long-term effects of breastfeeding, it has been evidenced that women who breastfed their babies have fewer rates of ovarian and breast cancer in later life (Blincoe, 2005; Jordan et al., 2012). They also have lower rates of type two diabetes mellitus and cardiovascular diseases (Leon-Cava et al., 2002; Blincoe, 2005). Breastfeeding for six months also reduces the risk of high blood pressure and cholesterol levels (Jonas et al., 2008; Horta et al., 2015). Women who breastfed for a duration of six months also found their weight reduced because breastfeeding affects fat metabolism when eating a varied and balanced diet (Dewey et al., 2001). In addition, breastfeeding delays the menstrual period for breastfeeding mothers, which works as a contraceptive measure by extending the time between pregnancies (Huffman and Labbok, 1994). Breastfeeding is also cost free and available at any time when compared with bottle feeding, which needs money and preparation.

1.5.3 Psychological benefits of breastfeeding The positive effects of breastfeeding go beyond physical benefits. According to Buckley (2015), for example, breastfeeding reduces emotional stress through the release of oxytocin. It also increases the bonding relationship between mothers and their babies (Else-Quest et al., 2003). Breastfeeding itself builds a unique bonding relationship between mothers and their babies and the interaction during breastfeeding has positive outcomes for infants’ lives (UNICEF, 2011). The current evidence is that breastfed infants have better psychological health compared with infants who received artificial milk (Bhargava, 1983). Breastfeeding decreases an infant’s discomfort and stress and,

27 therefore, plays an essential role in the child’s psychological development (Marquis, 2008). Breastfeeding gives relief to babies who feel pain, such as pain from a vaccination. Also, skin-to-skin contact through breastfeeding decreases stress and blood pressure, and maintain the temperature of the body and breathing rates of the infants (Gribble, 2006).

1.6 Definitions of Breastfeeding

Researchers require agreed definitions of breastfeeding in order to understand the experience of women who breastfeed (Noel-Weiss et al., 2012). It is important to develop definitions that could be used as standard terms to describe breastfeeding practice and will help in the accurate interpretation of research findings (Labbok and Krasovec, 1990). On 11-12 June 1991, a meeting was conducted by the WHO and UNICEF to consider definitions of breastfeeding indicators and to develop a standard definition to help classify breastfeeding practices (WHO, 1991). The WHO defined breastfeeding as the child receiving breast milk directly from the breast and starting within the first hour after childbirth (WHO, 1991). EBF means that infants should receive breast milk for the first six months after birth, no other food or drink, including water, but infants are entitled to receive drops and syrups, such as vitamins, minerals and medication (WHO, 1991). After that, infants should be provided with complementary foods and continue breastfeeding up to two years of age or more (WHO, 1991). The WHO definitions of breastfeeding are illustrated in Table 1.1.

28 Table 1.1: WHO definitions of breastfeeding

Breastfeeding categories Definitions

Breastfeeding The child has received breast milk (direct from the breast or expressed). Exclusive breastfeeding The infant has received only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, with the exception of drops or syrups consisting of vitamins, mineral supplements, or medicines. Predominant breastfeeding The infant’s predominant source of nourishment has been breast milk. However, the infant may also have received water and water-based drinks (sweetened and flavoured water, teas, infusions, etc.), fruit juice, oral rehydration salt solution, drop and syrup forms of vitamins, minerals, and medicines, and ritual fluids (in limited quantities). With the exception of fruit juice and sugar-water, no food-based fluid is allowed under this definition. Complementary The child has received both breast milk and solid (or breastfeeding semi-solid) food. Bottle feeding The child has received artificial milk.

(Source: WHO, 1991)

1.6.1 Definition of breastfeeding within the Omani context Despite the MOH in Oman following WHO definitions and descriptions of breastfeeding, Omani women continue to provide their baby with water mixed with red seeds (garden cress seeds) in the first six weeks after childbirth as a sociocultural practice. Within the Omani context, this practice is regarded as exclusive breastfeeding because women consider water containing those seeds to be a treatment or medicine for abdominal gases for their infants. The definition of EBF in this study is that of providing breast milk to a baby as well as water with garden cress seeds, with this mixture limited only to the period of six weeks after childbirth.

1.7 Breastfeeding Policies

It is known that exclusive breastfeeding in the first six months after childbirth is a foundation and gold standard for an infant’s health and survival. Many factors can influence EBF rates, such as sociocultural practices, health systems and lack of

29 knowledge (WHO, 2014). Commercial aspects and the policy makers involved in any country should also consider actions to increase EBF rates that include creating a supportive atmosphere for breastfeeding (WHO, 2014). Policy makers have also to establish policies that protect breastfeeding and support women while they are breastfeeding their baby exclusively for at least six months (WHO, 2014). It is also important to develop a policy to monitor the legislation of the International Code of Marketing of Breast-milk Substitutes by ensuring the proper usage and marketing of breast milk alternatives (WHO, 1981).

It is also important to establish a breastfeeding policy for working women. Many working women across the world will return to work before their babies reach six months of age (Heymann et al., 2013). Working women also need breastfeeding breaks in the workplace in order to meet the WHO recommendation of EBF for six months after birth (Heymann et al., 2013). According to the WHO, the lack of legislation regarding maternity leave and breastfeeding breaks that would support women’s ability to breastfeed their baby when they return to work has had an adverse effect on decreasing the EBF rate globally (WHO, 2014). Most countries worldwide have legislation regarding maternity leave. However, there are challenges in terms of extending breastfeeding breaks in the workplace (Heymann et al., 2013). In 142 countries around the world, women have the right to paid or unpaid breastfeeding breaks but 54 countries have still not constituted this vital guarantee for women in the workplace (Heymann et al., 2013).

1.8 Exclusive Breastfeeding Rate across the World

1.8.1 Exclusive breastfeeding rate in high-income countries Despite WHO efforts and a wide range of information about the health benefits of breastfeeding for women and their babies, a low EBF rate for the first six months after childbirth is apparent in high-income countries (Hamlyn et al., 2002). Over the last two decades, several high-income countries worldwide have put a great deal of effort into increasing EBF rates; the results are, however, modest. Many high-income countries have been struggling to maintain high rates of EBF. For example, in 2010 in the UK, according to an infant feeding survey conducted by the NHS information centre, 81% of mothers started breastfeeding after birth, but only 34% of mothers were breastfeeding when their child reached six months of age, and 0.5% of women were breastfeeding when their child reached twelve months after childbirth (Viner et al., 2018). In a similar survey, the EBF

30 rate at six weeks was 24% and reduced to 12% and 1% when a child reached four and six months after childbirth, respectively. The USA has also struggled to increase breastfeeding rates. According to the Centers for Disease Control and Prevention (CDC), in 2015, 83.2% of mothers initiated breastfeeding whilst in hospital but the EBF rate for infants then reduced sharply, from 46.9% at three months to 24.9% at six months (CDC, 2018). In addition to that, in a standardised survey in 11 European countries including The Netherlands, Denmark, Germany, Belgium, Ireland, Croatia, Italy, Norway, Sweden, Spain, and Switzerland, the findings showed a variation on breastfeeding rates (Theurich et al., 2019). In Europe, 56% and 98% of infants in all countries received breast milk directly after birth and at six months 13% to 39% of infants had been exclusively breastfed (Theurich et al., 2019).

1.8.2 Exclusive breastfeeding rate in low-and middle-income countries It is not only high-income countries that are struggling to maintain a high rate of exclusive breastfeeding; low- and middle-income countries have the same problem. Numerous attempts have been made to increase the rate of EBF in low- and middle-income countries, in which the incidence of child malnutrition and mortality is high (UNICEF, 2012). An analysis by Cai et al. (2012) of the prevalence of EBF across 140 low- and middle-income countries indicated that the rates of EBF increased from 33% in 1995 to 39% in 2010 for infants aged 0˗5 months. An increase in the rate was recorded in Africa (12% in 1995 to 28% in 2010) and modest improvements were noted in Asia (from 40% in 1995 to 45% in 2010) (Cai et al., 2012). Analysis by UNICEF also indicated that the rate of EBF in low- and middle-income countries among infants aged 4-6 months had increased to 40% in 2011 (Oot et al., 2016). These numbers indicate that there has only been a slight improvement in the EBF rate in low- and middle-income countries. Despite improvements in some regions, the prevalence of exclusive breastfeeding remains too low in many of the low- and middle-income areas of the world (Cai et al., 2012).

1.8.3 Exclusive breastfeeding rate in Gulf Cooperation Council Countries In the Gulf Cooperation Council (GCC), which includes the following countries: the Kingdom of Saudi Arabia (KSA), Qatar, Bahrain, the United Arab Emirates (UAE), the Republic of Yemen, and Oman, EBF rates were also at a low level and did not achieve the standard recommended by the WHO with regard to breastfeeding (UNICEF, 2012). All GCC members are considered high-income countries, apart from the Republic of

31 Yemen. According to the Gulf Health Council, in 2016, approximately 92% of mothers in the KSA initiated breastfeeding for newborns and the exclusive breastfeeding rate among Saudi women was 23.9% at three months after childbirth (GHC, 2016). In Bahrain, only 30% of infants below the age of six months were exclusively breastfed and 65% of Bahraini women were breastfeeding at the same time as providing artificial milk before their babies reached six months of age (GHC, 2016). In the UAE, mixed and complementary feeding were common breastfeeding practices among Emirati women in the first month after childbirth, and only 25% of infants were breastfed exclusively at six months (GHC, 2016). In Qatar, only 18.9% of infants under the age of six months received exclusive breastfeeding (GHC, 2016). Oman has also struggled to maintain high rates of EBF (MOH, 2015). The breastfeeding rate is low despite the implementation of the BFHI in 1992 (Al-Ghannami and Atwood, 2014). In Oman, the rate of EBF is 10.2% when the child reaches six months of age (GHC, 2016). Amongst GCC countries, Oman has the lowest rate of exclusive breastfeeding. However, it is important to mention that there are no statistics available regarding exclusive breastfeeding rates from the Republic of Yemen.

1.8.4 Factors affecting breastfeeding It is not yet known what factors affect breastfeeding in Oman. However, according to Al- Ghannami and Atwood (2014), the suboptimal breastfeeding practices in Oman have been connected to a lack of healthcare professionals’ support for breastfeeding women and the increased marketing of artificial feeding that started in the 1970s. The reasons for EBF decline are the presence of breast milk substitutes (artificial milk), insufficient knowledge and lack of support. Attitudes of people within their community may also lead to women’s feeling embarrassed about breastfeeding in public (Whelan and Kearney, 2015).

1.9 Study Context: The Sultanate of Oman

1.9.1 Geography Oman is one of the Arab countries and is located on the south-eastern coast of the Arabian Peninsula in the west of the continent of Asia. Oman is a member of the GCC and is adjacent to three other GCC countries on its land borders (the UAE, the KSA and the Republic of Yemen) and shares maritime boundaries with two countries: the Islamic Republic of Iran and the Islamic Republic of Pakistan. It is also surrounded by the Arabian

32 Sea, the Gulf of Oman and the Rub Al-Khali desert of the KSA. Oman is a coastal country and covers a total land area of 309,500 square kilometres (NCSI, 2014), with 82% of the land area composed of different geographical features, such as valleys and deserts, 15% of the land area is accounted for by mountains and 3% is formed by the coastal plain (NCSI, 2014). Except for Dhofar Governorate, which has a strong monsoon climate and warm winds from the Indian Ocean, the weather of Oman is very hot and dry most of the year. Administratively, Oman is divided into eleven governorates, with sixty-one wilayats (provinces), and Muscat, the capital city of Oman, is located in Muscat Governorate (Figure 1.1). Approximately half the population live in the Muscat and Al-Batinah governorates (NCSI, 2019). Thus, most of the social services and governmental facilities are located in those two governorates.

Figure 1.1: Map of the Sultanate of Oman (Source: Ministry of Health, Sultanate of Oman, 2016)

33 1.9.2 Demographic profile Between 2003 and 2010, the population in Oman increased by 2.4% (NCSI, 2014). By 2014, the total Oman population had increased to 3.99 million (NCSI, 2014). Based on information gathered by the National Centre for Statistics and Information (NCSI), the entire population of Oman was 5,222,583 in 2018 (NCSI, 2019). The total Omani population (i.e., those born in Oman) was 2,635,915 and 2,586,668 were members of a non-Omani population (born outside Oman) consisting of Arabs and non-Arabic groups, such as Egyptians, Somalis, Indians, Bangladeshis and Pakistanis (NCSI, 2019). Of the total Omani population, 1,371,420 were male and 1,264,495 female (NCSI, 2019) (Figure 1.2). According to statistics for Oman, 50% of the population is aged 25-54 years; thus, the Omani population is considered to be youthful and productive because half of them are of working age (NCSI, 2019). Of the total Omani population, 27% are female, of reproductive age and between 15 and 49 years old, and 13.9% are children under the age of five years (NCSI, 2019). Therefore, approximately 41% of the total Omani population consists of women of reproductive age and children below the age of five (MOH, 2014a). According to the NCSI (2018a), of the total Omani population in 2017, 42% were children aged between 0 and 17 years. The MOH predicts that the Omani population will increase and is expected to reach 7.9 million by the year 2050 (MOH, 2014b).

Figure 1.2: Population pyramid for the Sultanate of Oman (Source: Ministry of Health, Sultanate of Oman, 2016)

34 1.9.3 Development in Oman Oman is a high-income country with a secure social, economic and political system, as evidenced by the excellent relations between Oman and its neighbouring countries and other nations globally (WHO, 2006). According to the Global Peace Index (GPI), Oman is ranked the 74th most peaceful country in the world out of 195 countries (GPI, 2018). The two essential sources of Oman’s economy are oil and gas (Figgins et al., 2018). During the past forty years, Oman has witnessed tremendous changes in different fields of life and developed into a modernised country, in a short period of time, with a great deal of socioeconomic improvements, such as those seen in the economy and its health and education (WHO, 2006). Although a process of modernisation has taken place in different aspects of life in Oman, the Omani government led by Sultan Qaboos (who was the Sultan of Oman from 1970 until his death in January 2020) made efforts to ensure that the Omani people maintained their identity, by acknowledging the Omani social structure generally and the family in particular (Al-Barwani and Albeely, 2004). Although Oman has utilised its natural resources, such as oil and gas, to develop the country, the government has been mindful of its culture and heritage and encouraged its people to maintain an Arabic-Omani lifestyle (Al-Barwani and Albeely, 2007). The government invites Omani people to follow Islamic rules and traditional Omani practices in different aspects of their life. For example, both men and women are required to wear traditional Omani dress. Women still wear a long, wide black dress, called an abaya, when they leave the house and men wear a white robe called a dishdasha when leaving their home. Most Omani people also follow the same traditional practices during weddings, funerals and other aspects of life. However, although various aspects of the Omani community have been modernised, breastfeeding has remained the same: Omani women learn about breastfeeding from the previous generations and follow the same notion of breastfeeding practices. Women in Oman became educated but are still following in their mothers’ steps on breastfeeding practices.

1.9.4 Women’s status in Oman Omani women and Islam Oman is an Islamic country and most of its rules were obtained from Islamic principles, referred to as shariah. Islam grants equal rights to all Muslims, both men and women, as Allah states in the Holy Quran:

35 O mankind, indeed we have created you from male and female and made you peoples and tribes that you may know one another. Indeed, the most noble of you in the sight of Allah is the most righteous of you. Indeed, Allah is Knowing and Acquainted (Surat Al-Hujuraat, 49:13).

Islam also emphasises the importance of education and work for both men and women and the Prophet Muhammad (Peace Be Upon Him) encouraged female education. Khadijah, one of the wives of the Prophet Muhammad (Peace Be Upon Him), was a successful businesswoman and Aisha, another wife of the Prophet (Peace Be Upon Him) was a teacher, who taught women about Islamic principles and quoted many of the Prophet’s hadiths to Muslims; thus, they are considered role models for all Muslim women.

Omani women before 1970 Before 1970, women in Oman were confined to domestic roles and did not have jobs outside the home because their primary role was to serve their husband and children (Al Riyami et al., 2004). Childbearing and taking care of children were the most important roles of women in Oman and a high number of children was often seen in one Omani family (Al Riyami et al., 2004). Omani men were accountable for supporting the family and giving the essentials of life from the financial side (Al Riyami et al., 2004). Women received an Islamic education at the nearest masjid (mosque), called an almualim (teacher) (Al Riyami et al., 2004). There was no formal education for females due to the unavailability of schools for girls. At that time, only three governmental schools were available and those were limited to boys. In 1970, His Majesty Sultan Qaboos emphasised the importance of women’s education and employment (MOI, 2019), and thus there was a rapid increase in women’s education. Omani people became more open to women’s education and employment, as discussed in the following section.

Omani women after 1970 After His Majesty Sultan Qaboos assumed leadership in 1970, he always felt that, since women form half of Omani society, the education of girls should never be absent and that Omani women should be engaged in the education and work sectors (Al-Jarida Al- Rasmiya, 1973). The Omani government led by Sultan Qaboos gave Omani women a number of social rights, such as the right to education and to work, the same as Omani men (Al-Jarida Al-Rasmiya, 1973). Oman respects women and the country celebrates Omani Women’s Day on 17 October each year, an anniversary introduced in 2009 by His

36 Majesty Sultan Qaboos (Al-Jarida Al-Rasmiya, 2009). His Majesty Sultan Qaboos always emphasised the importance of teaching Omani women and, since 1970, fast development has taken place in the country’s educational area and government schools were established for girls. The number of schools increased from three in 1970 to 1,125 public schools and 636 private schools in 2017, which were distributed in all the governorates of Oman according to the density of the population (NCSI, 2018a). By 2017, 53.7% of female Omani students had joined various universities in Oman (NCSI, 2018a). Before 1970, women and girls were taught in mosques and learned the Quran and how to read and write (Al Riyami et al., 2004). After 1970, women and girls learned at government schools and the illiteracy rate reduced from 15.9% in 2011 to 6.2% in 2017 among Omani women (NCSI, 2018a). In the last forty years, Oman has changed tremendously in different fields of life, which have included Omani women’s employment. In 2018, 41% of Omani women were working in different sectors, compared with 31% in 2013 (NCSI, 2018a). Now, Omani women work beside Omani men in different professions, such as education and health. Both groups contribute to the development of Oman in various areas of endeavour.

Women in Oman now hold powerful senior managerial positions. For example, the Ministers of Education and Higher Education are both female. Other women hold political positions on the Omani Shura Council, the members of which are elected. The Omani Shura Council is composed of representatives chosen from the wilayats in Oman. Each wilayat chooses one or two candidates depending on the size of the population. It is essential to mention that, although aspects of their lives have been modernised, Omani women remain the primary carers for their children and the house, without consideration for their working status. Women are responsible for breastfeeding, following up their children in school and taking care of them when they are ill. Modernisation in different aspects of life has not affected breastfeeding practices or the role of women in Oman, and Omani women are still following their mothers’ notion of breastfeeding practices.

Maternity leave in Oman According to Royal Decree No. 35/2003, which relates to labour law in Oman, under article 83, women working in Oman are allowed to receive fifty days of maternity leave with full payment (Al-Jarida Al-Rasmiya, 2003). Maternity leave is allowed five times during a woman’s working life (Al-Jarida Al-Rasmiya, 2003). According to Omani labour law, although women are not limited in the number of births they can have, and

37 can give birth to any number of babies, they do have limited maternal leave: if women give birth after their fifth baby, they will not be given paid maternity leave. This is, of course, an issue among Omani women who work. Many working women have raised this issue with the Omani Shura Council in order to be given more days of maternity leave and to be allowed to have more births during their working lives but the issue has yet to be decided. Labour law in Oman also allows women who work to receive a full year of childcare leave, albeit without salary, if they request it (Al-Jarida Al-Rasmiya, 2003). There is also no specific policy on breastfeeding in the workplace in Oman, and there is no protected time for breastfeeding women in Oman when they are at work. Thus, it is crucial to empower women to breastfeed by developing a breastfeeding policy for the workplace. This policy will support working women during the breastfeeding period.

1.9.5 Family structure in Oman Islam emphasises the importance of the family for the individuals in any community (Dhami and Sheikh, 2000). The role of the family is connected to social and religious instruction and the family unit is considered to be the basis of a healthy community (Dhami and Sheikh, 2000). The family has a primary function in any community and is considered to be the basis of that community (DeFrain et al., 2009). The Omani community appreciates the family and its role in building the social life of the country as a whole. In Oman, as in many communities in the world, the establishment of the family is important in terms of its functions in strengthening childbirth and kinship relationships. Families in Oman are known to be either nuclear (a family of procreation) or extended (a family of orientation) (NCSI, 2017a). A nuclear family consists mainly of a husband, a wife, and their children, who live in one house. An extended family can include grandparents, uncles, aunts, cousins, and their children and this type of family system is mainly found in rural regions of Oman, such as the Interior and Dhofar governorates, where people like to be in social groups and gather with each other to share their experiences (NCSI, 2017a). Around 40% of Omani families live in an extended family home; however, at the present time, the nuclear family has become the preferred type of family structure within the Omani community (NCSI, 2017a).

Before the 1990s, the presence of the extended family structure in Oman was important and there were many functions for each member of that type of family. For example, older adults, such as grandparents, took care of their grandchildren, and younger adults worked outside the home to meet the needs of their family members. The role of men in Oman

38 was to provide for the financial needs of their family and support their family members physically and psychologically. This type of cooperative family was able to teach its children the essential principle of socialisation. It also prepared children to feel a sense of belonging to their family in particular and the community as a whole. The extended family structure changed in the 1990s to that of a nuclear family. The change from extended to nuclear family structure in Oman may be due to the effects of modernisation and the involvement of Omani women in the economic field. Nevertheless, today, this change in the Omani family structure is also related to the physical distance of the nuclear family from other members of the extended family. Familial relations and attachments between family members are still evident in Oman and family members still gather every weekend in the grandparents’ home and their relationships are strong. As a result of the family structure in Oman, the decision making among people in Oman is not an individual but a family decision (Al-Barwani and Albeely, 2007); this includes decisions related to breastfeeding.

1.9.6 Breastfeeding in Islam Oman is an Islamic country and around 86% of the Omani population are Muslim (WHO, 2006). In the Islamic religion, children are seen as a great blessing (Husain, 2000); thus, Islam instructs parents to take care of their children. Islam instructs Muslims to be good and kind to their family members, particularly their parents and children (Al-Khayat, 1997). Ignoring the duties and responsibilities of the family and its members is prohibited in Islam (Al-Khayat, 1997) and is considered a sin. Each family member has rights and duties towards the others (Al-Khayat, 1997). For example, women are responsible for taking care of their home and children, and men are expected to provide what the family requires, such as food and money.

Reflective of the importance of women’s role within the family, Islam emphasises respect for mothers and asks children to deal with their mother graciously. A person once went to the Prophet Muhammad (Peace Be Upon Him) and asked,

Who among people is most deserving of my fine treatment? The Prophet replied, your mother. He asked again, who next? Your mother, the Prophet replied again. He asked, who next? The Prophet said again, your mother. He again asked, then who? The Prophet said, then your father (Hadith).

This Hadith indicates that the Islamic religion honours the standing of the mother because of the pain and difficulty that mothers experience in raising their children (Husain, 2000).

39 It also indicates the value of mothers and the importance of children respecting their mother throughout their life and dealing with them kindly, especially when their mother grows older. Islam emphasises respect for mothers due to their patience when caring for their children and the pain associated with childbirth and breastfeeding.

Islam also asks that mothers take care of their children and Allah promises mothers that He will reward them for being patient. In the Holy Quran, Allah recommends breastfeeding for two years if women can breastfeed. Thus, most Muslim women adhere to this principle and seek to breastfeed their baby, although it is optional. Islam also provides legislation to protect children’s rights (Saeidi et al., 2014). Children’s rights are human rights for children with special consideration to the right of protection (Saeidi et al., 2014). There are many rights for children, such as the right to human identity and to basic needs, such as food, education and healthcare (Saeidi et al., 2014). Islam upholds the child’s right to breastfeed from his or her mother and calls on mothers to breastfeed their babies for two full years if the woman is able to breastfeed. However, it is essential to recognise that breastfeeding in Islam is optional for women and Allah gave parents the choice with regard to the decision and duration of breastfeeding. In Islam, it is preferred that women breastfeed their baby for two years, but it is not imperative for women to breastfeed if they are not able to. Omani women receive most childcare instructions from Islam and breastfeeding is one among the Islamic principles that women are advised to follow. Women follow the instructions of the Holy Quran and will try to breastfeed their baby until the child reaches the age of two years. However, they know that in Islam it is not compulsory to breastfeed a child for two years if there is a legitimate reason to do otherwise, such as illness.

1.9.7 Breastfeeding within the social context in Oman Breastfeeding is standard practice among Omani women, who learn about breastfeeding and its importance from inherited beliefs that are transferred from one generation to the next. Breastfeeding is one of the essential elements of maternal health in Oman (MOH, 2012). It is routine practice among Omani women and most of the adults in Oman indicate that their mothers breastfed them during infancy (Al Sinani, 2008). According to sociocultural practice in Oman, women live with their mother (the baby’s grandmother) for forty days (six weeks) after childbirth, enabling them to recover. During those six weeks, the grandmothers take care of the woman and her babies. They teach their daughters about different aspects of infant care, such as bathing the baby and

40 breastfeeding. Older family members also guide postnatal women in self-care and raising babies, such as in matters of nutrition and cleanliness. As this period is seen as an important time for both the mothers and their babies, grandmothers will prepare a special Omani maternal diet for the women, known in the Omani language as akil al murabiat, to increase milk production and to allow the mothers to recover their strength after childbirth.

In Oman, preparing the diet for breastfeeding women is a custom performed by older family members (grandmothers) for all women who give birth. It is believed that this diet serves many purposes. For example, fennel flowers help women to recover from the stress of labour, while ‘red seeds’ (garden cress seeds) and fenugreek are believed to provide proper nutrition for women and increase milk production. It is also believed that the seeds help remove clots from the woman’s uterus. This special Omani maternal diet also includes animal fat, known as samin, and a soup made of brown flour and herbs, referred to in the local language as sikana, which helps to improve milk production. After childbirth, women are often advised to eat food containing those ingredients. Moreover, red seeds and water are given to infants before they have reached six weeks of age, as it is believed the seeds help clean the stomach and intestinal tract of meconium and gases. This mixture is smooth and does not cause choking to infants. Red seeds (garden cress seeds) with water are administered by spoon on the side of babies’ mouth. This practice is a historical practice and its origins unknown. The practice is, however, the opposite of WHO recommendations regarding breastfeeding, as the WHO recommends that babies should not receive anything except breast milk.

1.10 Healthcare System in Oman

Before His Majesty Sultan Qaboos took power in Oman in 1970, there were only very limited healthcare services in the country. There were only two hospitals with a total twelve-bed capacity and ten clinics in the entire country (MOH, 2014b) and women birthed at home. After the renaissance of Oman in 1970, His Majesty emphasised the importance of developing health services in the different governorates in Oman. Health services in Oman have grown quickly over the last forty years, owing to this initiative (MOH, 2015). The MOH now encourages women to give birth in hospital (MOH, 2014b). Healthcare services are spread across all the governorates in Oman, dependent on the density of the population (MOH, 2015). For example, in 2017, there were fifty-four

41 government hospitals with a total capacity of 5,977 beds, along with twenty-three extended health centres and 184 health centres disseminated across all the governorates of Oman (MOH, 2014b). The health sector also includes twenty-one private hospitals with a total capacity of 725 beds, and 270 private health centres in the governorates (NCSI, 2017b). On average, each government hospital and each health centre serves about 606 and 14,971 patients, respectively (MOH, 2014b). The MOH is accountable for both the government and private healthcare institutions in Oman (NCSI, 2017b). The ministry also develops health plans and policies for the health services and is responsible for implementing them in all healthcare institutions in the country, whether private or government (MOH, 2015). The MOH is the leading provider of promotional, preventative, curative and rehabilitation facilities in the health sector in Oman (MOH, 2015) and, due to the improvement in the health sector, life expectancy for Omani people has increased and reached 78 years (MOH, 2016).

The health sector in Oman consists of extended health centres, health centres, and hospitals and provides primary, secondary and tertiary healthcare facilities in the healthcare institutions in Oman (MOH, 2013). As mentioned earlier, health services are distributed across all the governorates in Oman, depending on the density of the population. Extended health centres and primary health centres provide primary healthcare services, such as outpatient clinics, and some have a short-stay inpatient facility, such as an emergency department, to which patients are admitted for not more than 24 hours (MOH, 2013). An extended health centre provides outpatient access with different specialist services, such as ophthalmology, maternal and child healthcare, orthopaedic and internal medicine (MOH, 2015). People in all the governorates can access health services through the primary healthcare institutions, which are located in the same area in which they live. If people need a higher level of care, such as secondary healthcare services, a doctor in a primary healthcare institution refers them to a referral hospital in the same governorate (MOH, 2015). For example, people with complicated cases or critical illnesses can be referred from extended health centres to hospitals for assessment, treatment and admission to hospital. If cases are more complicated, the referral hospital in the governorate will refer the sick person to Muscat Governorate for specialised care by an expert. For example, coronary artery bypass grafting is only performed in Muscat Governorate, so people are referred to a specialised hospital for a specific medical procedure. The MOH charges Omani people only 1 Omani rial (2 pound

42 sterling) per year and each doctor’s visit costs 200 baisa (40 pence), which is considered cheap in comparison with other countries.

1.10.1 Maternal and child health services in Oman In 2014, the MOH in Oman developed its Health Vision 2050 (MOH, 2014b). The Vision was developed to enable all the people in Oman to live healthily, by establishing a well- organised and efficient healthcare system grounded in Omani values of social justice and equality (MOH, 2014b). The MOH also aims to improve the healthcare system and increase the capacity of healthcare professionals in Oman through comprehensive programmes, such as nutrition and school health initiatives and the Maternal and Child Health (MCH) programme (MOH, 2014b). The ministry also aims to consolidate better health for everyone in Oman, especially women and children (MOH, 2014b). For example, the MOH has been addressing women’s needs and children’s nutrition as part of its health programme (MOH, 2014b).

The MOH has developed many national programmes for women’s and children’s health, such as the MCH Services referred to above, which aims to promote the health of both women and their babies. In Oman, MCH Services were implemented August 1987 and began in all wilayats (MOH, 2013). These services aim to provide comprehensive care to mothers and their babies and to reduce morbidity and mortality rates among both women and infants (MOH, 2013). To achieve its objectives, the MOH also adopted the Primary Health Care (PHC) package, which includes a full programme of antenatal, birth, postnatal and birth spacing services to afford better care for women and their babies in Oman (MOH, 2014a). A breastfeeding promotion programme is included within the PHC package (MOH, 2013). Pregnant women can attend for six antenatal care visits in primary healthcare institutions and the primary care provider is a registered midwife. During their visits to antenatal clinics, pregnant women receive a range of services, such as immunisation, physical examinations and health education (MOH, 2013). Healthcare professionals also perform blood and urine investigations, as well as sonar and physical examinations. Pregnant women receive health education about risk factors during pregnancy, breastfeeding and nutrition. Women receive antenatal care in the health centre nearest their place of residence, have their birth in secondary healthcare institutions and, after childbirth, return to the same primary healthcare institution to follow up their postnatal care. The women go for two follow-up appointments. The first visit is after the second week and the second visit is after the sixth week following the birth. During those

43 visits, healthcare professionals assess the women’s health status, check if the women have complications, encourage the women to breastfeed, and discuss suitable birth spacing methods.

Since the application of the PHC package, the mortality rate of infants has reduced in Oman, as highlighted by several global agencies, including the WHO (MOH, 2014a). The infant mortality rate of the Omani population was estimated at 59.4 infant deaths per 1,000 live births from 1980 to 1985 and had decreased to 9.5 infant deaths per 1,000 live births by 2015 (MOH, 2015). This downward trend is predicted to continue and to reach four infant deaths per 1,000 live births in 2050 (MOH, 2014b). In addition, the under-five mortality average was estimated at 27 deaths per 1,000 live births in 2000 and had reduced to 12 by 2010 (MOH, 2015). This rate is projected to continue reducing to reach 4 deaths per 1,000 live births by 2050 (MOH, 2014b). There have also been fluctuations in the maternal mortality rate in Oman. For example, the maternal mortality rate reduced from 37.5 per 100 thousand live births in 2002 to 13.2 in 2006 (MOH, 2013). In 2009, it was reported to be 13.6 per 1,000 live births, 26.4 in 2010 and 17.8 in 2012 (MOH, 2013). This fluctuation in the rate of maternal mortality may be due to delays in seeking healthcare, reaching care or receiving proper care. Many studies discuss the reasons for maternal mortality such as poverty, malnutriton and poor maternal services (Kao et al., 1997; Loudon, 2000).

1.10.2 Baby-Friendly Hospital Initiative Despite the application of the BFHI in 1992, the EBF rate is low in Oman. According to the MOH in Oman, the EBF rate decreased from 95.1% at birth to 12.4% at six months in 2013 (MOH, 2013) (Figure 1.3). In 2016, the EBF rate reduced further, from 92.1% at birth to 10.2% at six months and 86% of infants in Oman received artificial milk at six months postnatal (MOH, 2016) (Figure 1.4).

44 100

80 Exclusive … 70

0 Birth 2 Months 3 Months 4 Months 5 Months 6 Months

Figure 1.3: Exclusive breastfeeding rate in 2013 (Source: Ministry of Health, Sultanate of Oman, 2013)

Figure 1.4: Exclusive breastfeeding and artificial feeding rates in 2016 (Source: Ministry of Health, Sultanate of Oman, 2016)

45 Oman has had remarkable achievements in all fields of life in the last four decades and particularly in the area of healthcare services. Among these achievements is the BFHI programme, which was established in 1992 to foster, motivate and support breastfeeding and complementary feeding (MOH, 2016). All hospitals in Oman are licensed to offer the BFHI (Al-Jawaldeh and Abul-Fadl, 2018). Breastfeeding policy in all healthcare institutions in Oman follows that of the global recommendations and interventions of the WHO and UNICEF (WHO, 2009b). This initiative is an international effort to protect, promote and support the practice of exclusive breastfeeding among infants (WHO, 2009b). In Oman, all maternity institutions are BFHI-designated, which means they adhere to the ten steps to successful breastfeeding and the International Code of Marketing Breast-milk Substitutes (WHO, 2009a).

The international code outlined above is a collection of recommendations to manage the marketing of breast milk substitutes, such as artificial feeding. It is part of the awareness of the poor infant feeding practices that can influence children’s health. The ten steps provide the basis for healthcare professional practice, particularly among midwives, to know breastfeeding information, acquire skills and provide the necessary support for breastfeeding women, in order to improve optimal breastfeeding and complementary feeding practices (WHO, 2009a).

1.11 Determinants of Breastfeeding

A number of factors affect breastfeeding rates. The WHO identified several factors that lead to a low rate of EBF, which include social, cultural, environmental, knowledge, and healthcare system-related features (Bai et al., 2009). Factors correlated with breastfeeding outcomes can be labelled in different ways. For example, factors can be classified as changeable or non-changeable (Al-Sahab et al., 2008). The changeable factors that affect breastfeeding rates are healthcare professionals’ knowledge, attitudes and support with regard to breastfeeding, hospital practices in supporting breastfeeding and breastfeeding women, and social and family support for breastfeeding (Al-Sahab et al., 2008). These factors can be modified through various methods, such as improving hospital practices towards a more baby-friendly environment for infants and mothers, improving health professionals’ knowledge and skills via training and educational programmes, and through interventions to educate members of the community. Maternal age, occupation status, level of education, ethnicity and parity are all examples of non-changeable factors

46 (Al-Sahab et al., 2008). These factors can help identify women who are less likely to breastfeed their infants in accordance with the WHO recommended duration. In Oman, it is not yet known what factors affect breastfeeding.

1.12 Rationale for the Study

According to an annual health report carried out by the MOH in Oman, the exclusive breastfeeding rate reduced from 92.1% at birth to 10.2% when the child had reached six months of age (MOH, 2016). According to Al-Ghannami and Atwood (2014), low rate of exclusive breastfeeding could be due to a lack of healthcare professionals’ support for breastfeeding women and increased marketing of artificial milk, which started in the 1970s. Thus, the current study is essential to understand the factors that affect breastfeeding from the women’s, their family’s and healthcare professionals’ points of view. It is also essential to identify the social processes underlying breastfeeding practices. In some high-income countries, women who receive breastfeeding support have a higher chance of continuing to breastfeed their babies than women who did not receive support (Britton et al., 2007). A study conducted in the USA also concluded that effective health education about breastfeeding and breastfeeding challenges was essential to improve the practice and the management of complications of breastfeeding, as well as to prepare women for breastfeeding (Ahluwalia et al., 2005). In Oman, no studies have been conducted thus far on breastfeeding support or health education and its effects on women’s experience during breastfeeding.

As the researcher is a nursing tutor in an MOH educational institution, the Oman College of Health Sciences, the findings of this research study will further assist in developing an educational module for healthcare institutions in Oman that is based on breastfeeding and breastfeeding support. This module may help breastfeeding counsellors, health educators, nurses, doctors and midwives to form a holistic plan to encourage and support Omani women to continue breastfeeding to at least six months postnatal.

1.13 Summary

Breastfeeding is considered crucial, not only for babies’ health, but also for the women’s well-being. The WHO provides global guidelines for infant and child feeding and supports the practice of breastfeeding for at least six months after childbirth, with continued breastfeeding, together with complementary foods, until the age of two years

47 (WHO, 2003). However, a low breastfeeding rate for the first six months is apparent in high- and low-income countries, despite a wide range of information regarding the health benefits of breastfeeding. Oman is also struggling to maintain a reasonable rate of breastfeeding. The national statistics available in Oman indicate a low breastfeeding rate when babies reach six months of age and half of women stop breastfeeding when their baby reaches four months of age. This low rate of breastfeeding suggests the need to explore the various perspectives surrounding breastfeeding among women in Oman. Therefore, this thesis presents different perspectives regarding breastfeeding among Omani women, their family members and healthcare professionals. It also examines exclusive breastfeeding as experienced by women in Oman and investigates the reasons for continuing or stopping breastfeeding at various lengths of time after childbirth. It is essential to identify the barriers to and facilitators of breastfeeding within the Omani context in order to provide guidelines or recommendations to improve EBF among Omani women. Breastfeeding among women in Oman is similar to the global practice of breastfeeding; however, the breastfeeding practice in Oman is unique in the way that it is affected by religious and cultural aspects.

A comprehensive review of the literature on women’s breastfeeding experiences from the available relevant primary studies is provided in the next chapter. The review will enhance insight by examining previous studies from across different countries.

Chapter Two: Literature Review

49 Literature Review

2.1 Overview

This chapter reviews the current literature on women’s experience of breastfeeding and provides a comprehensive analysis and discussion of those experiences as identified in the research. The chapter aims to enhance current understanding of the perceptions of breastfeeding women by interpreting their experiences while breastfeeding in depth. The literature examined in this chapter includes qualitative research studies that have explored mothers’ perspectives on breastfeeding. The review of women’s experiences in this chapter is intended to lead to a more comprehensive understanding of women’s perceptions of breastfeeding by exploring women’s feelings, needs, points of view and concerns while they are breastfeeding, including their day-to-day thoughts, attitudes and factors that influence those experiences. The initial search took place in September 2015, to include current studies it was updated in October 2019.

In this chapter, a summary of the positioning of the literature review in grounded theory is provided first. The rationale for selecting a narrative review in this study is then illustrated, as well as presenting the search strategy and description, synthesis and critical appraisal of the research studies reviewed. The strengths and limitations of the examined studies are discussed before the chapter concludes.

2.2 Positioning of the Literature Review in a Grounded Theory Study

For decades, there have been numerous criticisms regarding the timing of conducting a literature review in grounded theory (Charmaz, 2014). The most-debated topic concerns reviews of the literature conducted in the early stages of grounded theory (Birks and Mills, 2015). Glaser and Strauss (1967) encouraged researchers to “literally ignore the literature and focus on the area under study, in order to ensure that the emergence of categories will not be contaminated by concepts more suited to different areas” (p.37). Glaser (1978) also recommended that a literature review be delayed until after the data collection and analysis process has been completed, due to the impact of the researchers’ previous knowledge on data analysis and theory construction. Glaser (1978) remained inflexible with regard to postponing the literature review in grounded theory. However, there is a contradiction within some of Glaser’s writing in terms of theoretical sensitivity

50 (Urquhart, 2012), as Glaser (1998) also suggested that researchers review the theoretical literature generally and broadly.

Strauss took a similar stance to Glaser but changed his opinion over time, stating that in his earlier work with Glaser they had overemphasised the inductive side of grounded theory (Strauss and Corbin, 1998). In Basics of Qualitative Research, Corbin and Strauss (1990) recommended that conducting a literature review at an early stage of a research study would help researchers to understand the basic concepts of their study. Both recognised that researchers should use their experiences and knowledge of related literature to extend the analysis of their data, and emphasised the importance of using their knowledge and experiences to direct theoretical sampling and promote theoretical sensitivity (Corbin and Strauss, 1990). Carrying out a preliminary literature review before conducting a study can increase the rigour and theoretical sensitivity of the research, which may lead to new insights (Giles et al., 2013).

Further to the above considerations, in Constructing Grounded Theory, Charmaz (2006) identified that ethical requirements often demanded a preliminary literature review; however, she warned against conducting an in-depth literature review prior to the data collection. According to Charmaz (2006), researchers, especially novices, may be affected by current theories and force data into categories. Later, Bryant and Charmaz (2007) acknowledged that advice to postpone a literature review tends to come from experienced researchers who have comprehensive knowledge of the literature and concepts.

For this study, as the researcher is a PhD student and novice researcher, reviewing the existing literature was essential for her to determine the design of the research study. Conducting a literature review and providing a summary of published research studies was also a requirement for obtaining ethical approval from The University of Manchester (UOM). Furthermore, as a novice researcher, it was essential for the researcher to orient herself in relation to prior research studies conducted into exclusive breastfeeding. The researcher performed a general literature review at an early stage of this study, which enriched her understanding of the research topic (Lempert, 2007). This literature review was an ongoing process concurrent with the progress of the study. The researcher also performed a more comprehensive literature review at the analysis stage and at the time of writing the discussion chapter.

51 2.3 Rationale for Selecting a Narrative Review

The increase in evidence-based practice has led to a rise in the types of review to be found in the scientific literature (Grant and Booth, 2009). There are multiple types of literature reviews in terms of their purpose, strategy and analysis, such as scoping, narrative and systematic reviews (Smith and Noble, 2016). A review of the literature helps researchers to summarise and compile an enormous number of research studies on the phenomenon under investigation.

Researchers use a scoping review when they want to address a general question (Arksey and O'Malley, 2005). The research question in a scoping review may be formed at the outcome of an iterative process as researchers become more familiar with the literature (Levac et al., 2010). A scoping review can include various structured searches but might not involve an evaluation of the quality of the research studies involved (Arksey and O'Malley, 2005). The findings from a scoping review are also drawn from studies with different research designs.

A systematic review is defined as “A review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyse data from the studies that are included in the review” (Green, 2005, p. 270). Researchers use methods that they have selected before they form their research questions and they then intend to obtain and analyse studies that relate to and answer those questions (Hemingway and Brereton, 2009). Systematic reviews are intended to discuss problems by recognising, critically evaluating and combining the findings of relevant high-quality studies. Systematic reviews are characterised by being systematic, objective, clear and replicable (Hemingway and Brereton, 2009). Researchers include a systematic search process to find studies that address a specific research question (Hemingway and Brereton, 2009). They also conduct a systematic presentation and synthesis of the findings of their search (Hemingway and Brereton, 2009).

A narrative review was selected for the current study for many reasons. For example, a narrative review consists of a systematic search of the available literature, which helped the researcher in this case to summarise the studies around EBF experiences. The narrative review approach is also suitable for research studies that have a focused study question (Bent et al., 2004). A narrative review summarises various research studies and the outcomes of those studies are drawn into a comprehensive framework of

52 understanding provided by the various participants’ own experiences (Kirkevold, 1997). Another advantage of a narrative review is that it helps in understanding the differences in research topics and accepts shared experiences (Jones, 2004). A narrative review is convenient for broad and general topics under study (Collins and Fauser, 2005), the search and inclusion criteria are clear, and the review appraises a specific topic of research.

Another reason for selecting a narrative review for this study is that the approach is flexible in its review process. A narrative review helps to identify gaps in the literature, and it is one of the aims of this review to understand women’s experiences of EBF within the Omani context. The approach allowed the utilisation of descriptive phrases within existing research studies in order to create different perspectives regarding women and other participants with regard to EBF (Cronin et al., 2008). It also allowed for broader coverage of relevant qualitative research studies (Mays et al., 2005). Furthermore, it provides a way to develop an interpretive and narrative synthesis from a broad perspective, in this case, the experiences of breastfeeding women (Noblit and Hare, 1988). The narrative review method helped the researcher to generate a more extensive understanding of women’s experiences during breastfeeding, instead of simply summarising several studies (Sandelowski et al., 1997). Moreover, the approach provides insight into the findings of the different approaches within the framework of a qualitative research design (Cronin et al., 2008).

2.4 Aim of the Review

This narrative review is intended to provide a critical appraisal of empirical studies of the methods and design that have studied women’s experiences of EBF. It also aims to provide a comprehensive review of women’s experience of breastfeeding. Furthermore, the review aims to explore the research methods used and to identify any gaps in the existing literature about the phenomenon under study.

2.5 Question Related to the Review

How do mothers experience breastfeeding? This review question was chosen to develop the review and was considered appropriate to the overall aim of the study.

53 2.6 Search Strategy

The search strategy for this study was developed to target qualitative research studies in order to identify themes related to women’s experience of breastfeeding within the previous fifteen years (2005-2019) and to ensure that the research studies included would reflect current work on women’s experience of breastfeeding. Electronic searches of different databases were first conducted in September 2015 and updated in October 2019. The first step in a narrative review is to form a research question in order to search for relevant literature (Schardt et al., 2007). Thus, the PICo (Population, a phenomenon on Interest, Context) framework was used in this review to facilitate a literature search by listing the keywords in the research question and to analyse participants' experience and social phenomena (Stern et al., 2014). The following research question was formed: How do mothers experience breastfeeding? PICo was applied in the following way: Population (breastfeeding mothers), a phenomenon of Interest (breastfeeding experiences, support, perceptions, attitudes, views), Context (high- and low-income countries). The Boolean operator ‘OR’ was used to find references that included either of the identified keywords. ‘OR’ combines terms within categories to expand the number of research studies for consideration (Bettany-Saltikov, 2012). ‘AND’ was used during the search to find references containing all the identified keywords. ‘AND’ combines terms across categories to focus the search as a consequence reducing the number of research studies identified (Bettany-Saltikov, 2012). The search was further improved with the use of MeSH (Medical Subject Headings) suggested subject terms in the database by examining other keywords that have a similar meaning in order to map out additional search terms. Depending on the database used, truncation was also utilised during the search by adding * to a search word to increase the possibility of identifying various acronyms and spellings for the search terms (Bettany-Saltikov, 2012), such as breastfeeding, breastfeed and breast-feed. A wildcard (#) was also used during the search. The symbol # is used within the search word or at the end of a word (Bettany-Saltikov, 2012). A wildcard is utilised to search for alternative spellings of a word (Bettany-Saltikov, 2012). For example, wom#n can be woman and women. The search terms used are illustrated in Table 2.1.

54 Table 2.1: Key concepts in the review question and its search terms

Key Population Phenomenon of Context concepts Interest

Search Breastfeeding wom#n Breastfeed* High-income countries terms Breastfeeding Experiences Low- and middle- mother# income countries Perceptions

Knowledge

Attitudes

Behaviours

Feelings

Views

Perspectives

Supports

Barriers

Facilitators

Search AND/OR Boolean operators combining search terms, truncation* and a techniques wildcard #.

Identifying inclusion criteria assists researchers in understanding how the studies identified are related to the area under investigation. According to Green and Thorogood (2013), setting inclusion criteria also reduces researcher bias. Torgerson (2006) suggested that researchers should have transparent inclusion and exclusion criteria before starting a review. Inclusion and exclusion criteria were utilised in this review to narrow the search. The approach also helped ensure that the studies included were in line with the aims of this review. Qualitative studies on women’s experience regarding exclusive breastfeeding were the primary focus of interest in this review. Mixed-method research studies were also considered if they included a robust qualitative component by using interviews, focus groups or observations. Full-text studies published in English or Arabic between 2005

55 and 2019 were included in the review to ensure that the studies identified reflected a wide range of breastfeeding practices. The exclusion criteria were studies that had a particular focus on disadvantaged groups or an complication during pregnancy, such as teenage pregnancy, premature birth or gestational diabetes. Studies were also excluded if they used quantitative methods or were qualitative studies concerned with experiences other than those of postnatal mothers (e.g., healthcare professionals only, midwives or partner only) because the focus of this review was on broad aspects of the maternal experience. Secondary research studies, such as protocols, methodological papers, and conference reports, were also excluded. The inclusion and exclusion criteria used in order to maintain the review focus in this study are presented in Table 2.2.

Table 2.2: Inclusion and exclusion criteria for the literature review

Inclusion criteria Exclusion criteria

1. Breastfeeding women 1. Studies of pregnant women’s expectation of breastfeeding or intention only. Perceptions other than those of mothers, such as healthcare providers.

2. Healthy mothers 2. Women with an illness e.g., diabetes and pregnancy-induced hypertension.

3. Healthy term infants 3. Preterm infants or infants with congenital abnormalities or infants admitted to a neonatal intensive care unit (NICU).

4. Qualitative studies or mixed- 4. Quantitative studies, studies focusing on method studies if they included a implementing/evaluating breastfeeding robust qualitative component. initiatives, secondary research studies such as protocols and conference reports.

5. English- and Arabic-language 5. Studies published in languages other than literature published between 2005 English and Arabic and before 2005. and 2019.

56 In order to gain a thorough and detailed overview of relevant research studies, a wide range of databases was searched: CINAHL (Cumulative Index to Nursing and Allied Health Literature) via EBSCO, Medline (Medical Literature Analysis and Retrieval System Online) via OVID, PubMed (biomedical literature), PsycINFO (Ovid online), which is a database of literature in the field of psychology, Maternity and Infant Care, British Nursing Index, Web of Science, and the Cochrane Database of Systematic Reviews. The databases were selected because they include a wide range of electronic and non-electronic journals and cover different disciplines across health and the social sciences. The search strategy was based on the following keywords, their synonyms and truncations: “breastfeeding” and “women’s experience”. In addition to searching the databases, an internet search was conducted using Google Scholar and the references list of each study was hand searched for related articles and authors to follow up. The search outcomes were imported and saved in a reference manager (EndNote X5) and duplicate research studies were removed before the researcher started screening abstracts.

2.7 Quality Assessment of the Selected Studies

An appraisal was undertaken to assess the quality of the research studies included against predetermined criteria (Hawker et al., 2002). This type of appraisal of qualitative research is employed to judge the quality of the studies under consideration (Walsh and Downe, 2006). For this review, each study was reviewed using the Hawker et al. (2002) scoring tool (see Appendix 1). The checklist in the Hawker scoring tool contains nine questions to assess the fairness and consistency of studies in relation to the following: abstract and title, introduction and aims, method and data, sampling, ethics and bias, data analysis, findings, generalisability or transferability, and implications and usefulness. The nine questions use a four-point Likert scale: 1 (very poor), 2 (poor), 3 (fair) and 4 (good) (Hawker et al., 2002). The highest total score is 36 and the lowest is 9 (Hawker et al., 2002).

Most of the studies reviewed (n=30) were considered “good” with scores ranging from 28–32 out of 36 and few studies (n=4) were “fair” with scores ranging from 19-24 out of 36 (see Appendix 2). The Hawker scoring tool was selected for this review because it provides clarity in reporting and is appropriate for analysis. The Hawker scoring tool helps provide the researcher with the strengths and limitations of the reviewed studies. For this review, the intention was not to exclude any study based on quality alone. The

57 researcher critiqued different aspects of each reviewed study, such as the methodology, method, and the way the findings were presented. The clarity and methods used in the studies presented in this review were critiqued and the researcher considered the richness of the description of the breastfeeding experience in the studies reviewed. This review encompassed (n=31) qualitative studies that used a variety of methodologies and participants and (n=3) mixed-method studies with a strong qualitative component.

The studies included in the review employed a variety of methodologies and an appraisal was undertaken of each study by applying the checklist formulated by Hawker et al. (2002). The scoring tool allows reviewers to grade studies independently with a high degree of reliability (Hawker et al., 2002). Hawker et al.’s (2002) tool has a clear protocol and scoring system, which enabled the researcher to conduct a fair assessment of the studies included. The tool can also be used to evaluate the quality of studies that use different methodologies.

2.8 Findings from the Search

A total of 3,928 published studies were identified from various electronic databases and 40 published studies by hand searching the reference lists of identified studies; 2,881 studies were determined to be duplicates and were excluded after being imported into reference manager (EndNote X5). The titles and abstracts of the remaining research studies (1,087) were screened against the inclusion criteria for eligibility; 940 research studies were excluded after reviewing their title and abstract, leaving 147 studies. From those 147 published studies, full-text articles were read and an additional 113 studies excluded. These studies were mostly ineligible for inclusion for the following reasons: they were limited to the experiences of pregnant women only (n=37) or they focused on high-risk breastfeeding mothers (n=31). Some studies focused on women’s experience of the services that support breastfeeding (n=24), and thus did not study breastfeeding mothers, or focused only on the family members of breastfeeding mothers. An additional 17 articles were opinion pieces, editorials and guidelines and 4 studies were published in languages other than English and Arabic. Of the remaining full-text articles reviewed, 34 studies fulfilled all the inclusion criteria. The numerical data for the process of the identification and selection of relevant studies is shown in a flow diagram (Figure 2.1) below.

n=3,928 records identified through database searching; n=40 studies obtained through other sources

n=2,881 duplicated records Identification excluded

n=1,087 records remained after removal of duplicates

Screening n=1,087 records screened

using title and abstract

n=940 records excluded

n=113 records excluded n=147 articles assessed for because eligibility criteria not eligibility based on reading met

full papers • Did not include breastfeeding women (n=37)

• Focused on high risk Eligibility (n=31)

n=34 articles included in the • Only healthcare provider final review view of breastfeeding (n=24) • Opinions, editorials and guidelines (n=17) • Other languages (n=4)

n=34 qualitative studies

UK (n=10), USA (n=7), Canada (n=4), Australia (n=3), New Zealand

Included (n=2), Sweden (n=2), Turkey (n=1), Hong Kong (n=1), Norway (n=1), Ireland (n=1), Lebanon (n=1), Lao PDR (n=1)

Figure 2.1: Flow diagram of the literature search strategy

59 2.9 Description of the Synthesised Qualitative Studies

The narrative review involved 34 studies (n=31 qualitative studies that used a variety of methodologies and participants and n=3 mixed method with a strong qualitative component) (see Appendix 3). All the reviewed studies presented clear aims to explore the experiences of breastfeeding women, and some included perspectives on breastfeeding from healthcare providers. Thirty-one studies were conducted in high- income countries: UK (n=10), USA (n=7), Canada (n=4), Australia (n=3), New Zealand (n=2), Hong Kong (n=1), Norway (n=1), Sweden (n=2) and Ireland (n=1) (see Table 2.3). These countries have different settings, healthcare services and sociocultural contexts. Only three studies were conducted in low- and middle-income countries: Turkey (n=1), Lebanon (n=1) and the Lao People’s Democratic Republic (PDR) (n=1). No research studies were determined to have been conducted in GCC countries, or Oman in particular. Although the context of the studies set in low- and middle-income countries might not be similar to the sociocultural context in Oman, they were included in the review because they were related to the review question in this study and provided important data.

In this review, 11 studies utilised a specific qualitative methodology, such as phenomenology (n=6), grounded theory (n=2), and ethnography (n=1). The remaining studies (n=22) applied a generic qualitative design and (n=3) used mixed methods. The qualitative studies included in this review used a variety of data collection tools and many of the studies included used more than one data collection method, such as interviews (n=27), questionnaires (n=4), focus groups (n=10), and audio diaries (n=2). However, none of the researchers in the reviewed studies collected data using observation, which can be especially useful when investigating breastfeeding support in healthcare institutions.

Data triangulation was employed as a strategy in many of the studies by using different participants, such as breastfeeding women (primigravida and multigravida women), healthcare providers and family members of the breastfeeding women. Triangulation ensures the comprehensiveness of data by obtaining various perspectives of the event under investigation (Mays and Pope, 2000). In general, details of the participants and the recruitment process were of average standard in the reviewed studies and more detailed information was needed.

60 Table 2.3: Qualitative studies included in the review

Countries Number of studies References

UK 10 Andrew and Harvey, 2009; Brown and Lee, 2011; Ryan et al., 2011; Twamley et al., 2011; Williamson et al., 2011; Guyer et al., 2012; Hoddinott et al., 2012; Williamson and Mohamed, 2012; Hinsliff-Smith et al., 2014; Brown, 2016.

USA 7 Kelleher, 2006; Moore and Coty, 2006; Flaherman et al., 2012; Powell et al., 2014; Spencer et al., 2014; Hawley et al., 2015; Obeng et al., 2015.

Canada 4 Chen, 2010; Jessri et al., 2013; Chaput et al., 2015; Dietrich Leurer and Misskey, 2015.

Australia 3 Sheehan et al., 2009; Brouwer et al., 2012; Gallegos et al., 2013.

New Zealand 2 Manhire et al., 2007; McBride-Henry et al., 2009.

Sweden 2 Backstrom et al., 2010; Palmér et al., 2015.

Norway 1 Wandel et al., 2016.

Hong Kong 1 Tarrant et al., 2014.

Ireland 1 Whelan and Kearney, 2015.

Turkey 1 Demirtas et al., 2012.

Lebanon 1 Nabulsi, 2011.

Lao PDR 1 Lee et al., 2013.

61 2.10 Analysis and Synthesis of the Narrative Review Findings

There are no specific instructions or protocols for synthesising and integrating the findings of narrative literature reviews (Coughlan and Cronin, 2016). Thus, researchers need to discuss narrative review findings in terms of the various main concepts (Ferrari, 2015). For this review, synthesis was undertaken by reading all the studies included in the review to extract fundamental findings or concepts related to the review question. Then, similar and related data were grouped together into themes (see Table 2.4). The themes were then evaluated and refined and finally combined into the following four emerging themes:

• Breastfeeding motivators; • Social support for breastfeeding; • Breastfeeding experiences; and • Persistence.

62 Table 2.4: Themes identified from the narrative review

Themes Description Authors Breastfeeding Breast milk is the best. Moore and Coty, 2006; Manhire et al., 2007; Andrew and Harvey, 2009; McBride-Henry et motivators al., 2009; Chen, 2010; Brown and Lee, 2011; Nabulsi, 2011; Williamson et al., 2011; Motherhood. Brouwer et al., 2012; Demirtas et al., 2012; Hoddinott et al., 2012; Williamson and Natural process. Mohamed, 2012; Gallegos et al., 2013; Jessri et al., 2013; Lee et al., 2013; Powell et al., Religious influence. 2014; Spencer et al., 2014; Tarrant et al., 2014; Dietrich Leurer and Misskey, 2015; Hawley et al., 2015; Obeng et al., 2015; Brown, 2016; Wandel et al., 2016. Social support for Family support. Kelleher, 2006; Moore and Coty, 2006; Manhire et al., 2007; Andrew and Harvey, 2009; breastfeeding Sheehan et al., 2009; Backstrom et al., 2010; Brown and Lee, 2011; Nabulsi, 2011; Ryan et Friends/peer support. al., 2011; Twamley et al., 2011; Demirtas et al., 2012; Flaherman et al., 2012; Guyer et al., Healthcare providers’ support. 2012; Gallegos et al., 2013; Jessri et al., 2013; Hinsliff-Smith et al., 2014; Powell et al., 2014; Spencer et al., 2014; Tarrant et al., 2014; Chaput et al., 2015; Hawley et al., 2015; Obeng et al., 2015; Palmér et al., 2015; Whelan and Kearney, 2015; Brown, 2016; Wandel et al., 2016. Breastfeeding Positive experiences with breastfeeding. Kelleher, 2006; Moore and Coty, 2006; Manhire et al., 2007; Andrew and Harvey, 2009; experiences McBride-Henry et al., 2009; Chen, 2010; Brown and Lee, 2011; Nabulsi, 2011; Ryan et al., Negative experiences with breastfeeding. 2011; Twamley et al., 2011; Williamson et al., 2011; Brouwer et al., 2012; Demirtas et al., Guilt and failure. 2012; Flaherman et al., 2012; Guyer et al., 2012; Williamson and Mohamed, 2012; Gallegos et al., 2013; Jessri et al., 2013; Lee et al., 2013; Hinsliff-Smith et al., 2014; Powell et al., 2014; Spencer et al., 2014; Tarrant et al., 2014; Dietrich Leurer and Misskey, 2015; Hawley et al., 2015; Obeng et al., 2015; Palmér et al., 2015; Brown, 2016; Wandel et al., 2016. Persistence Women’s ability to continue breastfeeding in Kelleher, 2006; Manhire et al., 2007; Andrew and Harvey, 2009; McBride-Henry et al., spite of difficulties, such as convenience, 2009; Brown and Lee, 2011; Nabulsi, 2011; Twamley et al., 2011; Brouwer et al., 2012; commitment, confidence, baby’s positive Spencer et al., 2014; Dietrich Leurer and Misskey, 2015; Hawley et al., 2015; Palmér et response, and having support. al., 2015.

63 2.10.1 Breastfeeding motivators Of the studies in this review, twenty-two afforded data on this theme, which concerns the motivators that lead women to decide to breastfeed their baby (see Table 2.4). Many of the women in these studies expressed their motivation to breastfeed in different ways, such as “wanted to breastfeed”, “decided to breastfeed”, “desired to breastfeed” “intended to breastfeed” and “motivated to breastfeed” (Andrew and Harvey, 2009; Brown and Lee, 2011; Williamson and Mahomed, 2012; Lee et al., 2013; Powell et al., 2014; Brown et al., 2016). From the narrative review, it could be seen that many of the motivators that had influenced women’s decision to breastfeed were as follows: women perceiving that breast milk is the best, women connecting breastfeeding and motherhood, women considering breastfeeding as a natural process, and religious influences on women’s decision to breastfeed. These motivators are examined in turn in more detail in the following sections.

Breast milk is the best From the studies, one of the primary motivators of women’s decision to breastfeed was to give their baby the best food and the majority of the women considered breast milk to be the best (Andrew and Harvey, 2009; Williamson and Mahomed, 2012; Lee et al., 2013; Powell et al., 2014; Spencer et al., 2014; Brown, 2016). Evidence from the studies showed that many of the women who took part in the qualitative interviews recognised the benefits of breastfeeding for their infant and themselves and that this was the primary motivator to breastfeed (Moore and Coty, 2006; Nabulsi, 2011; Lee et al., 2013; Hawley et al., 2015; Obeng et al., 2015). Women were motivated to breastfeed because they knew that breast milk provides nutrition, vitamins and increased immunity for their baby (Moore and Coty, 2006; Nabulsi, 2011; Hawley et al., 2015; Obeng et al., 2015). Breastfeeding also indicated care for the baby and enhanced the physical and emotional bonding and attachment between mother and baby (McBride-Henry et al., 2009; Sheehan et al., 2009; Chen, 2010; Nabulsi, 2011; Williamson et al., 2011; Dietrich Leurer and Misskey, 2015; Hawley et al., 2015). Mothers in those studies believed that their children would be healthy, strong, and avoid diseases and allergies if they were breastfed (Moore and Coty, 2006; Manhire et al., 2007; Andrew and Harvey, 2009; Brown and Lee, 2011; Lee et al., 2013; Spencer et al., 2014; Obeng et al., 2015). Women who participated in the study by Spencer et al. (2014) described not only wanting to breastfeed, but also

64 needing to breastfeed and an important motivator for breastfeeding their baby was the health benefits of doing so. One of the mothers stated:

“I knew this was something that I felt; not just that I wanted to do, I needed to do for him.” (Spencer et al., 2014, p.978)

The women participants in a study by Lee et al. (2013) mentioned that their family members and midwives told them that breastfeeding was the best method and they encouraged them to breastfeed; thus, they were motivated to breastfeed.

Breastfeeding and motherhood Many of the studies referred to breastfeeding as both a biological process and a sociocultural activity (Williamson et al., 2011; Brouwer et al., 2012; Demirtas et al., 2012; Powell et al., 2014; Spencer et al., 2014; Hawley et al., 2015). Evidence from the studies demonstrated that many of the women connected breastfeeding with motherhood and believed that breastfeeding and taking care of their babies was the natural work of women, and thus they were motivated to breastfeed (McBride-Henry et al., 2009; Williamson et al., 2011; Hoddinott et al., 2012; Powell et al., 2014; Spencer et al., 2014). Many of the women believed that breastfeeding equalled being a mother, a good mother and a perfect mother (McBride-Henry et al., 2009; Williamson et al., 2011; Hoddinott et al., 2012; Powell et al., 2014; Spencer et al., 2014). The ability of women to breastfeed their baby was linked to being a good mother and the people surrounding the women would be happy as a result of the mother’s success at breastfeeding (Williamson et al., 2011; Brouwer et al., 2012). For example, one mother reported:

“I was really pleased that I could continue on and give my baby the best start in life.” (Brouwer et al., 2012, p.1348)

This statement supports the notion of positive attitudes towards breastfeeding. The women in these studies also believed that if they did not breastfeed their baby, people within their community would think that they were a failure; other women reported that if they did not breastfeed, their motherhood would be questioned and people would judge them negatively (McBride-Henry et al., 2009; Brouwer et al., 2012; Spencer et al., 2014). Many of the women felt pressurised due to issues with breastfeeding, such as pain while breastfeeding, sore nipples and difficulties in positioning the baby for breastfeeding, which led to their stopping breastfeeding (McBride-Henry et al., 2009; Brouwer et al., 2012).

65 Breastfeeding as a natural process Women in many of the studies identified that they were motivated to breastfeed their baby because they perceived breastfeeding as a natural process and they considered breast milk a natural food for their baby (Chen, 2010; Brown and Lee, 2011; Nabulsi, 2011; Williamson et al., 2011; Brouwer et al., 2012; Gallegos et al., 2013; Tarrant et al., 2014; Wandel et al., 2016). One of the women stated that

“Breastfeeding is the normal way to feed a baby. It is expected; It is natural.” (Brouwer et al., 2012, p.1349)

The women expected to breastfeed their baby because they thought that it would be easy, problem free, painless, straightforward and natural for them and their baby (Brown and Lee, 2011; Williamson et al., 2011; Tarrant et al., 2014; Wandel et al., 2016). One woman had a different notion, however, and stated that she had anticipated that breastfeeding would “not come easily”, as she had been listening to women who talked about their difficulties with breastfeeding (Brouwer et al., 2012, p. 1350). The studies also showed the importance of preparing for breastfeeding while the women were pregnant. Many of the women specified breastfeeding as a skill that needed to be learned, especially during pregnancy (Tarrant et al., 2014; Brown, 2016). Therefore, the women attended breastfeeding classes during the antenatal period and read books about breastfeeding as a form of preparation (Tarrant et al., 2014; Brown, 2016). Other women identified that they were not sufficiently prepared for the breastfeeding experience during the antenatal period (Tarrant et al., 2014).

Religious influences on women’s motivation to breastfeed Four studies (from Turkey, the UK, Canada and the USA, respectively) identified the influence of religion on women’s motivation to breastfeed their baby: Demirtas et al. (2012), Williamson and Mahomed (2012), Jessri et al. (2013) and Spencer et al. (2014). These findings are consistent with those in the current study, in which women talked about the influence of Islamic guidelines regarding breastfeeding on their intention to breastfeed. Beliefs that were rooted in Islamic teachings had motivated women to breastfeed (Demirtas et al., 2012; Williamson and Mahomed, 2012; Jessri et al., 2013). Mothers in those studies stated that they wanted to breastfeed their baby for two years, as recommended in the Holy Quran and advised by the Prophet Muhammad (Peace Be Upon Him) (Demirtas et al., 2012; Williamson and Mahomed, 2012; Jessri et al., 2013). The

66 women also believed that they were committed to breastfeeding their baby for two years. As mentioned by one woman: “If breast milk were not essential for the baby, God would not have provided it. It is useful since it has been created by God…That is why I wanted to breastfeed. Our religion prescribes that babies should be breastfed for two years...I had to fulfil my obligation as a mother.” (Demirtas et al., 2012, p.1114)

Spencer et al. (2014) included Muslim and Christian participants in his study and the women reported they were motivated to breastfeed their baby because they believed that God created breasts for feeding. One of the women stated:

“I think there is a reason that, you know, God designed it this way. I mean, God meant for us to do this.” (Spencer et al., 2014, p.981)

2.10.2 Social support for breastfeeding Among the studies synthesised, most of the mothers who participated reported that they desired receiving significant amounts of support while breastfeeding from a variety of sources, such as family members, friends and healthcare providers (Manhire et al., 2007; Sheehan et al., 2009; Brouwer et al., 2012; Tarrant et al., 2014; Chaput et al., 2015; Hawley et al., 2015). Support while breastfeeding was seen by the women as an essential factor in being able to breastfeed (Moore and Coty, 2006; Manhire et al., 2007; Gallegos et al., 2013; Obeng et al., 2015) and to the success of breastfeeding (Kelleher, 2006; Manhire et al., 2007; Powell et al., 2014; Chaput et al., 2015; Hawley et al., 2015). Spencer et al. (2014) reported that women who received different levels of support from their family members, friends and healthcare professionals continued breastfeeding. Many of the women felt frustrated and worried when the people they trusted would not support them while breastfeeding (Moore and Coty, 2006; Spencer et al., 2014). Many of the mothers also appreciated support that was based on counselling, making use of advice from women who had experience of breastfeeding, guidance from others, and receiving encouragement while breastfeeding (Manhire et al., 2007; Spencer et al., 2014). Synthesis of the theme of social support for breastfeeding in the studies revealed two sub-themes: healthcare professionals’ support and family and peer support. Breastfeeding support is identified in more detail in the following sections.

67 Healthcare professionals’ support Both primigravida and multigravida mothers expressed their need for help and support from healthcare providers when initiating breastfeeding after birth (Moore and Coty, 2006; Guyer et al., 2012; Wandel et al., 2016). Women also expressed their need for constant encouragement from healthcare professionals to breastfeed and to continue breastfeeding (Manhire et al., 2007; Sheehan et al., 2009; Hinsliff-Smith et al., 2014; Tarrant et al., 2014; Wandel et al., 2016). Evidence from the studies showed that there was a need for healthcare providers to spend time with women in maternal clinics and share information on breastfeeding techniques as well as challenges and their management with the women to solve breastfeeding problems (Backstrom et al., 2010; Hinsliff-Smith et al., 2014; Chaput et al., 2015; Hawley et al., 2015; Whelan and Kearney, 2015). The studies also identified that practical and emotional support from healthcare providers helped women’s determination and confidence to breastfeed and continue breastfeeding (Manhire et al., 2007; Andrew and Harvey, 2009; Backstrom et al., 2010; Twamley et al., 2011; Hinsliff-Smith et al., 2014; Tarrant et al., 2014; Palmér et al., 2015). For instance, one mother stated:

“I enjoyed breastfeeding as I know no one else could feed my child. I also was helped by the fact I got a lot of praise from midwives on the weight gains for my babies.” (Manhire et al., 2007, p.376)

In contrast, lack of support from healthcare professionals was shown to decrease women’s confidence in breastfeeding. As one woman stated:

“I had one midwife that made me feel really uncomfortable and felt that I could not do it...my confidence was gone so I thought I could not do it.” (Sheehan et al., 2009, p.16)

Some of the women in the studies also indicated that they obtained inconsistent, insufficient, inappropriate and conflicting advice from healthcare professionals, which was a problem for them and made them feel confused (Manhire et al., 2007; Backstrom et al., 2010; Whelan and Kearney, 2015; Wandel et al., 2016). For instance, one mother reported:

“because one says one thing and another says something different, you get a little confused, that’s how I feel.” (Backstrom et al., 2010, p.5)

Other women felt that healthcare professionals did not provide valuable support during their hospital stay (Hawley et al., 2015). Many of the mothers also described not receiving

68 enough information and support during their follow-up care from their healthcare providers about breastfeeding, and they would ask the women if they were bottle-feeding or breastfeeding (Spencer et al., 2014). It appeared from the studies that a lack of support from healthcare professionals affected women’s ability to breastfeed (Sheehan et al., 2009; Twamley et al., 2011; Jessri et al., 2013).

Family and peer support Breastfeeding support from family specifically and the community as a whole was considered an essential step for successful breastfeeding, especially in the early postnatal period, and appeared to be a critical promoter for many of the women to breastfeed (Nabulsi, 2011; Guyer et al., 2012; Jessri et al., 2013; Brown, 2016). Studies showed that breastfeeding support provided to breastfeeding mothers was given in different forms, and the women received support from their families, neighbours and friends (Brown and Lee, 2011; Demirtas et al., 2012; Jessri et al., 2013; Spencer et al., 2014). For example, many of the women considered their mother (the baby’s grandmother) to be an essential source of support, education and guidance after childbirth and they trusted their mother’s knowledge and advice (Moore and Coty, 2006; Andrew and Harvey, 2009; Demirtas et al., 2012; Jessri et al., 2013; Spencer et al., 2014; Brown, 2016). One woman reported:

“I trust my mother’s advice because she has breastfed nine children and had raised us healthy.” (Jessri et al., 2013, p.50)

Other women appreciated their partner’s support, such as by attending breastfeeding classes with the women and staying with them while breastfeeding (Moore and Coty, 2006; Andrew and Harvey, 2009; Guyer et al., 2012; Jessri et al., 2013).

Support helped many of the women to overcome their difficulties with breastfeeding (Sheehan et al., 2009; Brown and Lee, 2011; Ryan et al., 2011; Jessri et al., 2013). Women reported that they sought solutions to their problems during breastfeeding from family members and the surrounding community and explained that they followed some of the cultural prescriptions that they had learned from their social environment (Demirtas et al., 2012; Gallegos et al., 2013; Obeng et al., 2015). For example, one mother was happy with the advice provided to her by a neighbour with regard to recovering from a sore nipple infection (Demirtas et al., 2012). She reported:

“I grated soap and onion, I cooked both of them, I put it on my breast and I waited for one night, it was so helpful, my nipple got over the infection, and I could breastfeed my child.” (Demirtas et al., 2012, p.1114)

69 Some of the mothers also expressed extreme thankfulness for sources of support that helped them to accomplish breastfeeding, which included family members and friends (Brown and Lee, 2011; Gallegos et al., 2013; Spencer et al., 2014). It was evident from the studies that family and peer support had a positive impact on enabling mothers to continue breastfeeding (Moore and Coty, 2006; Manhire et al., 2007; Powell et al., 2014; Spencer et al., 2014; Brown, 2016). Other mothers expressed their belief in sharing breastfeeding experiences that promoted breastfeeding (Spencer et al., 2014; Hawley et al., 2015).

In contrast, it was clear that mothers who did not receive support from their family or friends stopped breastfeeding and started artificial feeding for their babies (Spencer et al., 2014; Tarrant et al., 2014). Those mothers expressed feelings of frustration when family members would not support them in their wish to breastfeed (Spencer et al., 2014). For example, some of the mothers’ mothers (grandmothers) had a negative attitude to breastfeeding and others preferred artificial feeding, which affected the women in continuing to breastfeed (Moore and Coty, 2006; Twamley et al., 2011; Demirtas et al., 2012). The beliefs and knowledge of family members were one of the factors contributing to women stopping breastfeeding. Many studies from different countries have discussed the lack of the presence of family members when breastfeeding (Manhire et al., 2007; Demirtas et al., 2012; Guyer et al., 2012; Spencer et al., 2014; Tarrant et al., 2014). The desire of family members, especially older ones, to introduce artificial feeding or to have the mothers express their breast milk into a bottle increased pressure on women to stop breastfeeding (Manhire et al., 2007; Demirtas et al., 2012). In addition, some of the women did not regard their husband as a source of support to continue breastfeeding and thus they stopped breastfeeding (Guyer et al., 2012; Spencer et al., 2014; Tarrant et al., 2014). One woman described her husband’s support as a form of pressure to stop breastfeeding, and stated:

“I was getting pressure from my husband really to give it all up and bottle feed.” (Guyer et al., 2012, p.728)

2.10.3 Breastfeeding experiences This section identifies women’s experiences with breastfeeding. It was evident from the review that breastfeeding women faced a diverse range of experiences with breastfeeding, both positive and negative. From the studies, it appeared that some women had positive

70 experiences during breastfeeding, but many of them had negative ones. These experiences and their consequences are explored in the following sections.

Positive experiences with breastfeeding Across the studies in this review, some women had positive experiences with breastfeeding and described how they appreciated breastfeeding due to the health benefits for them and their baby, the opportunity for bonding, and the emotional relationship with their baby (Moore and Coty, 2006; Brown and Lee, 2011; Brouwer et al., 2012; Spencer et al., 2014; Dietrich Leurer and Misskey, 2015). One mother stated:

“I enjoy breastfeeding him, it gives me a wonderful closeness and satisfaction.” (Brown and Lee, 2011, p.199)

Women also mentioned the economic advantages of breastfeeding, such as saving money, and the time it saved by not having to prepare bottles (Andrew and Harvey, 2009; Spencer et al., 2014). Those women were delighted with their breastfeeding experiences and used words such as “proud”, “enjoy”, “happy”, “great”, “awesome”, “amazing” and “loved” (Brown and Lee, 2011; Nabulsi, 2011; Brouwer et al., 2012; Jessri et al., 2013; Spencer et al., 2014; Dietrich Leurer and Misskey, 2015). One woman reported:

“I am glad I did it, and was proud and happy to have carried on as long as I did. This was the longest breastfeeding relationship of my three.” (Dietrich Leurer and Misskey, 2015, p.3) Other women linked positive breastfeeding experiences to how easy breastfeeding was for them and they had not encountered any problems (Moore and Coty, 2006; Brown and Lee, 2011; Brouwer et al., 2012; Dietrich Leurer and Misskey, 2015).

Many of the women who took part in the studies talked openly about their sense of pride in their ability to feed their babies from their own bodies as a part of motherhood (Chen, 2010; Williamson et al., 2011; Brouwer et al., 2012; Hawley et al., 2015). Most of the mothers reported that breastfeeding is not only a natural but an essential part of motherhood (Chen, 2010; Williamson et al., 2011; Brouwer et al., 2012). For example, one mother reported:

“It is amazing that you can actually feed somebody else from your own body…I feel much more self-contained and able to look after him than if I was dependent on a bottle.” (Williamson et al., 2011, p. 439)

71 It also appeared from the studies that some women mentioned that their previous positive experience with breastfeeding helped to make their current experience positive as well (Manhire et al., 2007; Jessri et al., 2013). For some of the women, a positive experience increased their confidence with breastfeeding (Moore and Coty, 2006; Twamley et al., 2011; Brouwer et al., 2012; Jessri et al., 2013). However, other women were not able to continue breastfeeding due to challenges they experienced (Moore and Coty, 2006; Twamley et al., 2011), which are identified in the next section.

Negative experiences with breastfeeding It was recognised that women in different studies had connected breastfeeding with mothering, motherhood and being a good or perfect mother (McBride-Henry et al., 2009; Williamson et al., 2011; Hoddinott et al., 2012; Powell et al., 2014; Spencer et al., 2014). Many of the women expected breastfeeding to be easy, straightforward and without pain (Brown and Lee, 2011; Williamson et al., 2011; Tarrant et al., 2014; Wandel et al., 2016). However, some of the women described their experiences with breastfeeding as difficult, a struggle, overwhelming and stressful during the early challenges (McBride-Henry et al., 2009; Williamson et al., 2011; Brouwer et al., 2012; Lee et al., 2013; Tarrant et al., 2014). The mismatch between women’s expectations and the reality of breastfeeding also had an impact on the duration of breastfeeding (Brouwer et al., 2012; Hinsliff-Smith et al., 2014; Tarrant et al., 2014; Palmér et al., 2015).

Many of the studies identified physical challenges relating to women’s experiences during breastfeeding, such as pain while breastfeeding, sore nipples, and compressed (inverted) nipples (Kelleher, 2006; Andrew and Harvey, 2009; Nabulsi, 2011; Lee et al., 2013; Spencer et al., 2014; Tarrant et al., 2014; Hawley et al., 2015). Many of the mothers reported pain while breastfeeding. They also revealed that they had cracked nipples and others had compressed nipples, which prevented their infant latching appropriately to the breast and resulted in a painful and frustrating experience while breastfeeding (Kelleher, 2006; Andrew and Harvey, 2009; Nabulsi, 2011; Lee et al., 2013; Spencer et al., 2014; Tarrant et al., 2014; Hawley et al., 2015). It seems that physical discomfort could have an impact on women’s decision to stop breastfeeding (Andrew and Harvey, 2009; Nabulsi, 2011; Lee et al., 2013; Spencer et al., 2014; Tarrant et al., 2014; Hawley et al., 2015). One woman reported:

“My nipples became very sore and cracked quickly, I could not continue breastfeeding.” (Manhire et al., 2007, p.378)

72 Other commonly cited negative experiences with breastfeeding were clustered around women’s perception of having insufficient milk (Demirtas et al., 2012; Flaherman et al., 2012; Jessri et al., 2013; Lee et al., 2013; Tarrant et al., 2014; Obeng et al., 2015). The women believed that the reasons for insufficient milk were lack of sleep or rest and inadequate dietary intake (Jessri et al., 2013; Lee et al., 2013). Other women were uncertain about the amount of breast milk needed for their baby and they thought that they needed the same amount of artificial milk; to resolve their uncertainty, they provided artificial milk for their baby (Tarrant et al., 2014; Obeng et al., 2015). Women also believed that they did not produce enough milk due to their baby’s crying and thus provided artificial milk for their child (Demirtas et al., 2012). Some of the women also believed that breast milk does not contain sufficient nutrition for babies and that babies would need more nutrients as they grew, so the women provided artificial milk as well (Williamson et al., 2011; Lee et al., 2013).

Breastfeeding in public was another of the negative experiences described by many of the women. Some of the women identified a religious influence as one of the reasons for discomfort (Williamson and Mahomed, 2012; Jessri et al., 2013). For example, it is forbidden for Muslim women to breastfeed in front of any male but their husband (Williamson and Mahomed, 2012; Jessri et al., 2013). Other women felt embarrassed about breastfeeding in public because they considered the breast to be a sexual object (Twamley et al., 2011; Brouwer et al., 2012; Hinsliff-Smith et al., 2014). Some of the women did not breastfeed due to lack of private rooms in public places (Twamley et al., 2011; Brouwer et al., 2012; Jessri et al., 2013; Hinsliff-Smith et al., 2014). As a result, some women preferred to provide a bottle feed for their baby and others covered their breast with scarves, blankets, towels or cloths to avoid being stared at (Twamley et al., 2011; Brouwer et al., 2012; Williamson and Mahomed, 2012; Gallegos et al., 2013; Jessri et al., 2013; Spencer et al., 2014). One woman reported:

“I knew for me even during my pregnancy that breastfeeding in public was going to be the issue.” (Brouwer et al., 2012, p.1348)

In addition, women had different opinions about breastfeeding in front of other female relatives or non-relatives. Some women felt comfortable about breastfeeding in front of other females, while others did not (Williamson and Mahomed, 2012; Gallegos et al., 2013; Hinsliff-Smith et al., 2014; Spencer et al., 2014). It was evident that women felt

73 shame with regard to breastfeeding in public because of the lack of social support available in that situation (Brouwer et al., 2012; Gallegos et al., 2013; Jessri et al., 2013).

Employment outside the home also affected women’s experiences of breastfeeding. Many of the women in the studies returned to work within one to four months after childbirth due to financial problems (Moore and Coty, 2006; Nabulsi, 2011; Jessri et al., 2013; Lee et al., 2013; Spencer et al., 2014). Many of the women discussed issues they had with the lack of support in their workplace, such as not having any private rooms in which to pump their breast milk (Moore and Coty, 2006; Brown and Lee, 2011; Nabulsi, 2011; Jessri et al., 2013; Lee et al., 2013; Powell et al., 2014; Obeng et al., 2015). Working women experienced conflict between breastfeeding and expectations at work, which influenced breastfeeding duration (Brown and Lee, 2011; Nabulsi, 2011; Jessri et al., 2013; Lee et al., 2013). Many working women stopped breastfeeding after they returned to work because they could not balance work and breastfeeding (Brown and Lee, 2011; Nabulsi, 2011; Jessri et al., 2013; Lee et al., 2013). One woman stated:

“At one point my boss came to me and was like you are pumping too much, which kind of irritated me, I was pretty offended.” (Powell et al., 2014, p.262)

Only a few women reported positive support from their workplace (Powell et al., 2014). Other women talked about their physical tiredness and inability to balance breastfeeding with work and that was why they decided to stop breastfeeding (Moore and Coty, 2006; Brown and Lee, 2011; Nabulsi, 2011; Lee et al., 2013). One woman reported:

“It is very difficult…I have to breastfeed, plus my work at home and my job…I stopped breastfeeding because of work.” (Nabulsi, 2011, p.4)

Across the studies in this review, many of the women with negative experiences could not continue breastfeeding; other women decided to stop breastfeeding due to feelings of being overwhelmed or a sense of worry, doubt or frustration (Williamson et al., 2011; Brouwer et al., 2012; Tarrant et al., 2014; Hawley et al., 2015). It was evident that many of the women who stopped breastfeeding described their experiences as a failure and felt guilty (Williamson et al., 2011; Brouwer et al., 2012; Guyer et al., 2012; Hinsliff-Smith et al., 2014; Powell et al., 2014; Tarrant et al., 2014; Hawley et al., 2015). One mother stated:

“When I stopped, I felt empty and could not help it. It felt like something was missing. I did not know why. I was a bit down at that time.” (Tarrant et al., 2014, p.1092)

74 The difficult decision to stop breastfeeding caused sadness, depression and a feeling of guilt for mothers who made that choice (Williamson et al., 2011; Brouwer et al., 2012; Guyer et al., 2012; Tarrant et al., 2014). One of the mothers reported:

“I cried because I thought I was useless. I cried because I was not able to feed her.” (Tarrant et al., 2014, p.1092)

Some of the women emphasised the need to obtain honest, accurate and reliable information from healthcare professionals about breastfeeding experiences (Hinsliff- Smith et al., 2014; Powell et al., 2014). Those women had not expected problems with breastfeeding; when they started breastfeeding, however, they realised the difficulties and could not continue breastfeeding (Hinsliff-Smith et al., 2014; Powell et al., 2014).

Not all women expressed a feeling of guilt when they stopped breastfeeding. Some of the women expressed relief after stopping breastfeeding because of their feelings of stress and difficulties while breastfeeding (Brouwer et al., 2012; Tarrant et al., 2014). One of the women commented:

“I felt more comfortable after I stopped breastfeeding because I did not have to feed every two hours and other people could help me to feed the baby.” (Tarrant et al., 2014, p.1092)

Some of the women had mixed emotions regarding breastfeeding. On the one hand, they felt guilty and sad because they stopped breastfeeding and, on the other, they felt relief and were more comfortable because they identified that their baby now received adequate milk (Nabulsi, 2011; Flaherman et al., 2012; Lee et al., 2013; Tarrant et al., 2014). It was evident from the studies that women stopped breastfeeding when it was connected with negative experiences (Williamson et al., 2011; Brouwer et al., 2012; Guyer et al., 2012; Tarrant et al., 2014). Some of the women continued breastfeeding despite the difficulties and their reasons are identified in the next section.

2.10.4 Persistence Across the studies in this review, some of the women decided to continue breastfeeding in spite of the discomfort and difficulties they experienced (Moore and Coty, 2006; Manhire et al., 2007; Twamley et al., 2011; Brouwer et al., 2012). Some of the women believed that if they stopped breastfeeding, the goal of mothering would be questioned and thus they felt pressure to continue breastfeeding (Jessri et al., 2013; Spencer et al., 2014). Those women continued breastfeeding to avoid being labelled a failure (Jessri et al., 2013; Spencer et al., 2014). In contrast, other women had feelings of commitment and

75 confidence, which were two main factors identified in the studies for continuing to breastfeed (Moore and Coty, 2006; Manhire et al., 2007; Twamley et al., 2011; Brouwer et al., 2012; Spencer et al., 2014). One woman mentioned:

“when you start breastfeeding there is always a few problems, so it was hard, I have to admit. I had sore breasts and sore nipples, so I was like ‘ooh, this is ...’ But you just have to push through it, and because I was quite stubborn, I was quite determined to do it.” (Twamley et al., 2011, p.599)

It was also evident that support was one of the reasons for many of the women deciding to continue breastfeeding, despite the difficulties (Moore and Coty, 2006; Manhire et al., 2007; Twamley et al., 2011; Spencer et al., 2014).Women mentioned that physical and psychological support from others, such as family members, friends or healthcare professionals, increased their willingness to continue breastfeeding (Moore and Coty, 2006; Manhire et al., 2007; Twamley et al., 2011; Spencer et al., 2014). For example, one woman reported:

“I got a lot of praise from midwives on the weight gains for my baby. That made me feel good and made me continue – even in the first week when it was easier to stick them on the bottle and avoid the dramas.” (Manhire et al., 2007, p.376)

Some of the women across the studies expressed that support, especially from family and friends, was essential to increasing their confidence to continue breastfeeding (Manhire et al., 2007; Backstrom et al., 2010; Chaput et al., 2015; Palmér et al., 2015).

The above review demonstrates that women were also encouraged to continue breastfeeding when they were progressing well with it and when they felt that it was becoming easier and more comfortable (Manhire et al., 2007; Brouwer et al., 2012). Other women continued breastfeeding when their baby had a positive response to it (Palmér et al., 2015).

2.11 Summary of the Literature Review Findings

As stated above, this narrative review included thirty-one qualitative studies and three mixed-method studies. Many of the research studies in this review were from high- income countries; only three studies were from low- and middle-income countries (Turkey, Lebanon and the Lao PDR). The studies were assessed for quality by utilising the scoring tool formulated by Hawker et al. (2002) and the majority of the studies were considered “good”. The findings of the studies identified a number of motivators that influenced women’s decision to breastfeed. The motivators include the women’s

76 perception of breast milk as the best, the relationship between breastfeeding and motherhood, women’s consideration of breastfeeding as a natural process, and religious influences on women’s decision to breastfeed. The findings of the studies also highlighted the importance of social support, such as from family members and friends, in breastfeeding duration. The findings indicated that the greater the support for breastfeeding, the longer the breastfeeding continued. The findings also indicated the importance of healthcare providers offering information and support to breastfeeding women during the antenatal and postnatal periods. In addition, the studies stressed the impact of women’s positive and negative experiences on breastfeeding duration and why some women were still breastfeeding in the presence of breastfeeding difficulties.

This review deepens our understanding of women’s breastfeeding experiences in different settings. The findings of this review are essential to helping to incorporate the actual experiences of mothers into professional caregiving and support strategies aimed at enhancing effective breastfeeding.

2.12 Strengths and Limitations of the Review

Among the thirty-four studies identified for this review, many used comprehensive methods, especially in their data collection and analysis processes, which was one of the strengths of the narrative review. The majority of the studies included also used different methods of collecting data, such as interviews, focus groups and audio diaries, which promotes the credibility of the studies’ findings. However, in some of the studies in this review, the authors did not state their methodology and sampling processes, so it was difficult to identify if the data collection and analysis procedures were appropriate; this was considered one of the limitations of the literature review. The majority of the studies included focused on exploring women’s perceptions of breastfeeding and a few studies included the opinion of family members and healthcare professionals on breastfeeding and its support. Involvement of the perspectives of family members and healthcare professionals is essential to gaining a comprehensive understanding of breastfeeding. This narrative review provides insight into the experiences of breastfeeding women from their own perspective. The majority of the studies considered in this review were conducted in high-income countries and aimed to describe the issues of women’s experiences of breastfeeding in order to improve the quality of the practice. However, within the Omani context, no qualitative studies that explore the daily experiences of

77 breastfeeding women were recorded. Only one study used a quantitative methodology to examine the prevalence and duration of breastfeeding in one area of Oman (Suliman et al., 1992). Thus, future research should employ qualitative in-depth interviews and a longitudinal approach to provide insight into the unique experiences of breastfeeding women in Oman.

The overall quality of the evidence in this narrative review was good (scores ranging from 28–32). However, in some studies, it was noted that most abstracts were unstructured and lacked sufficient detail to evaluate them thoroughly. The abstracts required information, such as aims and methods. Also, several studies provided limited, or no information regarding essential aspects of the study, such as sampling approaches used; participant recruitment procedures; ethical issues; reliability and validity. For most qualitative studies, the issue of reflexivity (the influence of the researcher on the research) was not acknowledged by the researchers. Furthermore, mixed-methods studies did not discuss the methods they used to synthesise qualitative findings. Lack of these details would affect the credibility of the evidence.

2.13 Conclusion

In this chapter, relevant qualitative research studies into women’s experiences of breastfeeding were examined and an in-depth understanding of the experiences of breastfeeding women was reached. The narrative review of the literature provided valuable insights into women’s motivators for breastfeeding and the importance of support for women in order for them to continue breastfeeding. It also provided understanding of women’s positive and negative experiences and their impact on the duration of breastfeeding.

It was found in 2013 that exclusive breastfeeding in Oman decreased significantly from 95.1% at birth to 12.4% when the child reached six months of age (MOH, 2013). In 2016, the EBF rate reduced further, from 92.1% at birth to 10.2% at six months (MOH, 2016). Thus, it is vital to explore breastfeeding practices in Oman by examining the women’s experience. Furthermore, it was identified in this chapter that few quantitative studies have been conducted in GCC countries and only one quantitative research study has been carried out in Oman regarding breastfeeding. One national survey was conducted in 1992 to examine the prevalence and duration of breastfeeding in one area of Oman (Suliman

78 et al., 1992). There have been no attempts to explore mothers’ experiences of breastfeeding in GCC countries generally and Oman in particular. Therefore, this study is an endeavour to fill the current knowledge gaps in Oman regarding exclusive breastfeeding. This will be the first qualitative study to use a grounded theory approach to explore exclusive breastfeeding among mothers in Oman. By studying the experiences and perspectives of breastfeeding mothers and other participants, this study will contribute to better understanding of breastfeeding in Oman and how to promote it.

This study is of importance to mothers, healthcare professionals, policy makers and the whole community, as it provides further understanding of breastfeeding. This research will contribute to the health services offered by the Ministry of Health in Oman, such as by identifying wrong practices or promoting new ones regarding breastfeeding in healthcare institutions. An understanding of breastfeeding women’s experience is essential in order to develop an educational programme in Oman regarding breastfeeding based on women’s needs and to build a culturally sensitive breastfeeding programme. The theory that emerged from this study will help other researchers to study different aspects of breastfeeding in Oman; thus, this research will serve as a basis for future studies. The following chapter presents the methodology and methods followed by this research study.

Chapter Three: Methodology and Methods

80 Methodology and Methods

3.1 Overview

This chapter describes in detail the methodology and methods used in this research study. It illustrates the research aims and objectives and discusses the general philosophical and theoretical underpinnings of the research study. It also justifies the selection of grounded theory as a guide to the research methods used. The chapter comprehensively describes the study’s qualitative approach and illustrates in detail the methods applied. It also presents an account of how grounded theory strategies were utilised in the data collection and analysis stages to increase the rigour of the research study.

3.2 Study Aims and Objectives

3.2.1 (Denzin and Lincoln, 1998)Study aims This research study was conducted in order to explore women’s experiences of EBF in the Omani context. It also had the aim of developing a theory grounded in women’s experiences of EBF.

3.2.2 Study objectives • To determine Omani women’s perceptions of EBF. • To explore how Omani women experience EBF. • To identify the barriers and facilitators related to EBF. • To explore the views of family members on EBF and how they support women who are breastfeeding. • To gain an understanding of healthcare professionals’ opinions of EBF and how they support breastfeeding women in healthcare institutions.

3.3 Philosophical Underpinnings of Research

It is crucial to determine the paradigm that will influence the theoretical and philosophical underpinnings of a study (Guba and Lincoln, 1994). Researchers need, for example, to identify the underlying ontological and epistemological presumptions of their research study (Scotland, 2012). These presumptions refer to the researcher’s selected methodology and how the presumptions match the research findings (Scotland, 2012). Crotty (1998, p. 3) defined the term ‘epistemology’ as the “theory of knowledge, a way

81 of understanding and explaining how we know what we know”. In other words, epistemology is about how individuals interpret the world or how they understand what they know. Ontology is defined as the methods for building facts and reality: “how things really are” and “how things really work” (Denzin and Lincoln, 1998, p. 201). According to Strauss and Corbin (1998), ontology is the theory of objects and their correlation. It is about researchers’ view of the nature of truth or the world and what is true. Once researchers determine their philosophical opinions and positions, the methodology comes easily (Urquhart, 2012). A methodology indicates the “process or design lying behind the choice and use of particular methods” (Crotty, 1998, p. 3). The theoretical perspective relates to the design and methods of a research study that involves the analysis of results (Denzin and Lincoln, 1994). According to Urquhart (2012), research design and philosophy need to be steady and consistent. Consistency and uniformity between theoretical and methodological strategies are meaningful in determining the way researchers inspect the social setting and in adding rigour to a study (Denzin and Lincoln, 1994). Thus, according to Denzin and Lincoln (1994), the philosophical notions of epistemology, ontology, and methodology cannot be separated.

3.4 Study Paradigms

A research paradigm is defined as a “set of beliefs and feelings about the world and how it should be understood and studied” (Guba and Lincoln, 1994, p. 17). Paradigm is a word used to describe how researchers look at the world. It is informed by philosophical presumptions about truth and ways of understanding what they know (Patton, 2002). Paradigms help researchers to ask certain questions and apply appropriate strategies to understand how to study the social world (Patton, 2002). There are multiple paradigms in a research study; however, positivism, interpretivism and constructivism are the three philosophical paradigms considered to be the central approaches to research methods.

The positivist standpoint is that utilising the scientific method is the only way to verify truth and reality (Bogdan and Biklen, 2003). Positivism is a kind of philosophical truth that adheres to the hypothetico-deductive strategy (McGrath and Johnson, 2003). It is commonly believed to be the leading philosophy underlying quantitative methods (McGrath and Johnson, 2003). Today, positivism is seen as being objectivist, which means that the things around us have meaning, regardless of our awareness of them (Crotty, 1998). Ontologically, positivists believe that the world is external and that reality

82 is separate from researchers’ interests and what is researched (Wahyuni, 2012). They believe that the social world, which exists separately from people, can be measured (Urquhart, 2012). According to positivists, there is one reality to any research aspect (Hudson and Ozanne, 1988). Consequently, they use a structured and organised method in research by recognising a clear research question and using an appropriate research methodology (Sarantakos, 2012). Moreover, the goal of positivists is to make the context free of generalisations; they assume that this is possible because individual actions are preceded by and determined by actual causes (Hudson and Ozanne, 1988). Accordingly, they attempt to separate themselves from the participants in their research studies (Sarantakos, 2012).

The epistemological side of positivism recommends that facts should be examined empirically, validated and verified (Eichelberger, 1989). Positivists work in a deductive way to find causal relationships (Urquhart, 2012). They also believe that truth can be recognised through scientific methods, such as the mathematical techniques of the quantitative research process (Gray, 2013). Thus, questionnaires and tests are their primary methods of data collection. Within this context, the goal of research is to discover principles that can be used to lead the world and predict circumstances (Avis, 2005). In addition, positivists attempt to persist in being open-minded, emotionally neutral and separate from their research participants, by ensuring a distance exists between themselves and those who take part in the research study (Hudson and Ozanne, 1988). According to positivists, this is an essential step in distinguishing between science and the researcher’s experience; consequently, they use systematic methods for their research (Carson et al., 2001).

Interpretivism and constructivism are similar notions that address understanding the social world as experienced by others (Neuman, 1997). However, there is some variation between the two paradigms. Interpretivist researchers integrate human interest within a study; thus, they believe that reality is socially constructed from language and meaning (Neuman, 1997). Interpretivism developed from criticism of the positivist paradigm in the social sciences. The interpretivist paradigm emphasises qualitative over quantitative analysis. Interpretivism is a humanistic philosophy based on an understanding of the social lives of the research participants (Bowling, 2014). Interpretivism is intended to be used to explain and gain a deep understanding of social situations through an inductive approach (Gray, 2013).

83 From an ontological standpoint, interpretivists believe that reality cannot be separated from the social actors (research participants and the researcher) (Creswell and Poth, 2017) and that many social realities are unpredictable and cannot be disconnected from the participants (Hudson and Ozanne, 1988). Interpretivists also believe that human life is a process of interpreting interactions with the social world (Weber, 2004). They assume that truth cannot be understood independently of the people who make that reality (Urquhart, 2012). From an epistemological aspect, interpretivist researchers recognise that knowledge is derived from socially constructed concepts and meaning (Weber, 2004). Their aim is to construct interpretations of meaning (Urquhart, 2012). They also believe that truth lies within the human experience. Therefore, the participants’ social life is described through fieldwork based on interviews and observations (Hudson and Ozanne, 1988). These data collection methods are flexible in order to obtain the meanings in and explanations of individuals’ interaction and to describe what is understood as truth (Hudson and Ozanne, 1988). According to Hudson and Ozanne (1988), mutual understanding between researchers and participants is an essential tool in interpretivist research. Researchers try to stay open to new information and data (Charmaz, 2014). Researchers take an active role by engaging passionately in the process of theory construction. Therefore, researchers cannot be separated from their research. The reality will be discovered by mutual relationship between the researchers and the participants. The interpretivism paradigm can be criticised for the objectivity lost, such as having many interpretations and realities (Weaver and Olson, 2005). This problem is overcome through reflexivity and constant articulation for rigour when examining the social interaction (Denzin and Lincoln, 1998).

The constructivism paradigm aims to understand the social realities between the study participants and the researcher. This paradigm allows the reconstruction of multiple views of various participants across the culture. Understanding the social realities is obtained for the interactions between the researcher and the research participants, which creates shared knowledge (the findings of the study). This shared knowledge is derived from expressing the reality of the participants and the researcher understanding and interpretation of participants’ social realities. Participants construct their realities and refine them through interactions with the researcher. The role of the researcher is to facilitate the process of constructing reality. From the ontological stance of constructivists, they believe that there are many realities, which differ from one person to

84 another, and that this reality is constructed. The epistemological side of constructivists acknowledges subjectivity, which means that researchers know of the influence of their perceptions and thoughts on their interpretation of the data (Houghton et al., 2012). Constructivists interact with participants to give a reconstructive understanding (Guba and Lincoln, 1994). This interaction with participants may influence the quality or credibility of a theory (Markey et al., 2014). However, constructivists overcome this issue by collecting data from various perspectives and providing a thick description of those data, which enhances the truthfulness of the material they use in their research (Houghton et al., 2012).

3.5 Underpinning Assumptions

One of the important steps for researchers to take is to decide their philosophical position (Birks and Mills, 2015). Each individual has a unique conceptualisation of reality (Birks and Mills, 2015). This study aimed to explore women’s experience of EBF and to elicit the perspectives of the women, their family and healthcare professionals regarding EBF. Constructivist grounded theory allows the exploration of participants’ experience in an interpretive way (Charmaz, 2006). The work of this study was based on the interpretive method because its focus is on how the participants’ social experiences were understood (Mason, 2002). It is essential for researchers to identify their philosophical position, as this creates a holistic view of how knowledge is seen and how the researchers see themselves in relation to knowledge (Urquhart, 2012). Ontology and epistemology can be used to describe how researchers view the truth. In this study, the researcher used an ontology based on social meanings, which considers that the world contains individuals who have their own ideas and meanings. The researcher believes that individuals view their world and perceive the meaning of reality based on their cultural contexts (Mills et al., 2006). Individuals understand the social world through social interaction and the way they interpret that social world. The researcher also believes that there are many truths rather than one truth (Guba, 1990). These realities are socially constructed through continuous refining between the researcher and the research participants (Weber, 2004).

Epistemologically, this study took a constructionist stance. Crotty (1998, p. 42) provides the following valuable summary of constructionism: “knowledge, and therefore all meaningful reality as such, is contingent upon human practices being constructed in and out of the interaction between human beings and their world...meaning is not discovered

85 but constructed”. The researcher believes that reality is socially constructed through the interactions between the researcher and the research participants (Schwandt, 1997). For this study, the meaning of EBF was constructed from the perspectives of breastfeeding women, their family and healthcare professionals, as well as the researcher’s understanding and interpretation of EBF. Understanding EBF was accomplished through the communications between the researcher and the research participants. The research participants constructed their realities and meanings of EBF and refined them through discussions and interactions with the researcher. Thus, the interpretive paradigm was considered appropriate for this research study because it respects the idea that knowledge is socially constructed.

Qualitative researchers also need to be clear about the theoretical perspective of their research. The ontological stance of the researcher involved examining the meanings and interpretations of the research participants and the epistemological position taken was one of constructivism. Thus, the researcher’s position identified symbolic interactionism as the theoretical perspective of this study.

3.6 Theoretical Perspective: Symbolic Interactionism

A theoretical perspective is defined as the “theoretical stance informing the methodology” (Crotty, 1998, p. 3). It is a lens through which researchers view events or phenomena. The theoretical perspective of this study is symbolic interactionism, which is the predominant theoretical perspective correlated with grounded theory (Charmaz, 2014). It is a way of describing social interaction and taking social interaction into account (Blumer, 1969). This theoretical perspective views individual activities as constructing society and acknowledges that people act in response to how they see their situations (Charmaz, 2014). The philosopher George Herbert Mead (1863–1931), the originator of symbolic interactionism, wrote about his theory of the development of a social self in his book, Mind, Self and Society (Mead, 1934). Mead’s theory concentrates on interpretation and interaction (Mead, 1934). Mead (1934) stated that interaction is the correlation between three elements: the mind, the self, and society, and these elements are not separate. Symbolic interactionism emphasises the value of language for the self and the social world and realises that human life is made up of essential objects (Charmaz, 2014; Charmaz et al., 2019). The general principle of symbolic interactionism is that an individual’s actions towards others are obtained from the meanings that others hold about

86 themselves (Blumer, 1969). These meanings are established from social interaction with other individuals, which indicates that there is an internal process of self-interpretation in individuals. According to Mead (1934), the important characteristic of symbolic interactionism is that every person has a self and is involved with objects and other people in an act. This act includes social interaction and combined action, which contribute to the community (Blumer, 1969). During such an act, people interact with themselves and with other people based on their explanations and interpretations (Blumer, 1969). Meaning is regarded as being obtained from social interaction and then altered via interpretation.

Blumer (1969) identified three core principles of symbolic interactionism: “people develop their thoughts about things based on the meanings that the things proposed to them” (p.275). Those meanings develop from the social interactions between the people within their community and the usage of meaning can change as a result of interactions between people and their interpretation (Blumer, 1969). The three core principles of symbolic interactionism support the production of personal meaning in people’s interactions with other individuals (Charmaz, 2005). The three core principles are appropriate to this study because the research participants act and react based on the meanings they have built for EBF (Blumer, 1969). Breastfeeding women’s interpretations of their experiences are shaped by their social interaction within their social context: for example, within their close families and with the surrounding community. Consequently, to understand EBF experiences, the researcher interacted with breastfeeding women and other participants of this study to understand their views and to consider matters from their perspectives. For instance, the perceptions and attitudes of breastfeeding women towards breastfeeding might be affected by their interpretation of what EBF means for them and any breastfeeding challenges they have encountered. In this study, the researcher’s interaction with the women allowed understanding of the different meanings of the women’s experience with EBF and the views of other participants with regard to EBF. Thus, symbolic interactionism allowed the researcher to examine the world that determines women’s behaviour and meanings as understood by the participants and to understand the situation from the participants’ point of view. The researcher was able to understand the participants’ opinions of EBF in detail due to her background and experience.

87 In a qualitative study, grounded theory is used jointly with symbolic interactionism (Glaser and Strauss, 1967). Both are used to study people and their social interaction (Gray, 2013). Grounded theory draws its theoretical underpinnings from symbolic interactionism (Charmaz, 2014) and acknowledges that incidents and events are not stable but change depending on conditions (Strauss, 1987). This theoretical perspective informed the methodology of the current research study.

3.7 Study Design

This study used a qualitative design. Qualitative research has a long history in social science studies (Murphy et al., 1998). Using a qualitative approach, researchers can examine broad dimensions of the social world, such as the everyday life experiences of research participants and their interactions and relationships (Mason, 2002). This study was undertaken to explore breastfeeding women’s experiences of EBF within the Omani social context and examined barriers and facilitators related to EBF. It also aimed to explore EBF from different perspectives, such as those of family members and healthcare professionals, and how the latter support breastfeeding women during the breastfeeding period. Qualitative research was used in this study to understand women’s perceptions of and attitudes towards EBF by exploring their experiences in detail and following flexible methods that are sensitive to the Omani social setting.

Qualitative methods of data collection have been identified as the most suitable way of exploring perspectives, views, and beliefs about an experience (Creswell, 1998). Qualitative research studies try to explain social phenomena in terms of the meanings people give to them, making the research method interpretive. It includes the nature of human experience and what phenomena mean to the research participants (Holloway and Wheeler, 2013). According to Creswell (2014), qualitative research is useful when a problem is inadequately understood or little researched. It provides a set of flexible tools that can be utilised in terms of their fit with the nature of the research question posed (Richards and Morse, 2013). Qualitative research methods are regarded as helpful tools for understanding people’s complexities in relation to experiencing life because this approach aims to “touch the core of what is going on rather than just skimming the surface” (Greenhalgh and Taylor, 1997, p. 740). The approach also allows and empowers research participants to talk about their experiences in their own language (Creswell, 2014). The qualitative approach was used for the current study because it was a good

88 match for the research objectives. It was considered an appropriate way of understanding the experience of the participants more profoundly than would have been possible using another set of methods (Creswell, 2014). The researcher has a background in and experience of EBF and qualitative research was helpful to explore a detailed picture of the phenomenon under study by using probing questions, which helped to understand EBF from the participants’ perspectives.

A grounded theory approach is used to guide a study that has the aim of developing a theory that explains how people regard their world and interact with it (Glaser and Strauss, 1967; Charmaz, 2000). Grounded theory is deemed the most appropriate approach to investigating social relationships and actions when there is limited research on the factors that affect people’s experiences (Charmaz, 2014). It also allows people’s lives to be seen holistically and from their own perspectives (Charmaz, 2014). It is a methodology or set of guidelines for providing both a description and an explanation of social processes during people’s interactions within the structure of a conceptualised theory through the systematic collection and analysis of data (Charmaz, 2000). For this study, the researcher communicated with breastfeeding women, their family members and healthcare professionals to interpret their words regarding EBF. The researcher also discussed the issue of EBF with the research participants to help in understanding the topic under study in more detail.

The most standard approaches to conducting qualitative research are phenomenology, ethnography and grounded theory. Phenomenology is an inductive method, aimed at understanding social reality from the viewpoint of the people who live it, without any modification by the researcher’s knowledge or assumptions (Gray, 2013). A German mathematician, Edmund Husserl (1859–1938), is recognised as the ‘father’ of phenomenology (Koch, 1996). Husserl explored foundations on which science could be created. He advised researchers to seek reality, ‘the things themselves’ (Husserl, 1970, p. 266). The aim of phenomenology is the rigorous and unbiased study of things as they appear in order to understand human experience (Husserl, 1970). Husserl devised the approach of phenomenological reduction in order to hold subjective views and theoretical constructs in abeyance and aid the emergence of the essence of the phenomenon (Husserl, 1970). Also, he argued that the ‘Lifeworld’ should be understood based on what people experience pre- reflectively before we have used ways of understanding or explaining it (Husserl, 1970). Husserl advocated ‘putting aside’ any presumptions about the subject

89 (bracketing), thereby enabling the essence of the phenomenon to appear. This method places the researcher as a separated and unemotional observer (Paley, 1997). Phenomenology focuses more on subjective human experience or meaning of the lived experiences of several individuals; and describes what all participants have in common about the phenomena under study (Dykes, 2004). Phenomenology aims to study human phenomena in an effort to illustrate the lived experiences and give them meaning from a single perspective (Gray, 2013). However, the study aims to obtain an in-depth understanding of the social processes associated with women who are breastfeeding.

Ethnography is also an inductive approach which aims to give an account of the unique cultural characteristics of a particular community (Hammersley, 2013). Ethnographic studies focus on culture and describing shared and learned patterns of values, beliefs and practices of a whole cultural group (Creswell, 2009). This group of individuals may interact over a period of time as the researcher observes the groups. However, ethnography requires researchers to have a lengthy time in the field to collect data (Brewer, 2000). The ethnographic stance would not have been appropriate for researching the experiences of breastfeeding women because the intention of this study was not cultural understanding of breastfeeding. Therefore, grounded theory was selected as a methodology for the current research. The intent for grounded theory is to go beyond description and generate a theory of actions, interactions or processes based on data collected from study participants (Corbin and Strauss, 2008). This means that participants in this study would all have experienced the process or the interaction. The challenge with the grounded theory is that researchers may encounter difficulties to decide when the theory is adequately detailed (Creswell and Poth, 2017). Nevertheless, the researcher believed that an understanding of the experiences of women, their family members and healthcare professionals could be illustrated through a qualitative method informed by using grounded theory methodology.

3.8 Grounded Theory Methodology

The principles of grounded theory directed the methodology of the current study. Grounded theory has been applied widely in healthcare research and particularly in the nursing field (Corbin, 1998). For example, Charmaz (1990) examined chronically ill people’s experiences using a grounded theory methodology. In this methodology, researchers use specific strategies, such as constant comparative analysis, theoretical

90 sampling and theoretical coding. Grounded theory is utilised to study fields in which little research has been done (Burns and Grove, 2001). This methodology helps researchers to build a theoretical understanding of the phenomena being studied by understanding how individuals perceive their world through social interaction (Burns and Grove, 2001). Grounded theory is a flexible and well-organised method that includes a concurrent and iterative process of data collection and analysis (Charmaz, 2014). It uses an inductive approach to produce an explanatory theory of individuals’ actions when examining the data obtained (Charmaz, 2014). In this study, it allowed the researcher to examine participants’ perspectives and to understand the meaning of EBF as shared between the participants and contextual factors. Thus, the grounded theory methodology was considered suitable for this study.

3.8.1 Overview of grounded theory Grounded theory methodology was established at the University of California, San Francisco by two sociologists, Barney Glaser and Anselm Strauss, in the 1960s. In their book The Discovery of Grounded Theory, Glaser and Strauss showed the strategies that they adopted in a cooperative study on dying (Glaser and Strauss, 1967). The book was first published as “a process that articulated the discovery of theory from qualitative data” (Robrecht, 1995, p. 170). Glaser and Strauss (1967) described their own research methodology as deducing theory from data. The approach explains the process or behaviour that is under study and is considered an approach to constructing a theory that is grounded in data that are gathered and analysed in a systematic way (Strauss and Corbin, 1994). The grounded theory method focuses on discovering a theory to help researchers understand a phenomenon, instead of proving an existing theory (Glaser and Strauss, 1967). Therefore, it can be seen that such researchers “search for social processes present in human interaction” (Hutchinson and Wilson, 1993, p. 181). Researchers aim to identify processes and know how people understand their reality by their social interactions (Hutchinson and Wilson, 1993).

There was a conflict between Glaser and Strauss over how to apply the grounded theory method after the original publication in 1967. They disagreed about the precise nature of the methodology and, as a result, discontinued their professional collaboration (Charmaz, 2000). Glaser is, however, recognised as “having retained both the spirit and the substance of the original work” (Locke, 2001, p. 64). His subsequent publications, together with The Discovery of Grounded Theory (1967) referred to above, provide detailed accounts

91 of the fundamental principles of the method (Glaser, 1998), whereas Strauss (with Corbin) is considered to have reformulated the original version (Strauss and Corbin, 1998), resulting in a division between Straussian and Glaserian approaches. The separation occurred after Strauss published a book called Qualitative Analysis for Social Scientists in 1987 (Charmaz, 2000). Strauss and Corbin later published another book, Basics of Qualitative Research: Grounded Theory Procedures and Techniques, in 1990 (Strauss and Corbin, 1990). Two years later, Glaser published another book highlighting the differences between different versions of grounded theory, in which he argued that his version was the original grounded theory (Glaser, 1992). According to Glaser, what Strauss and Corbin published was not grounded theory but a kind of qualitative data analysis (Glaser, 1992). This variation in methodology became a matter of academic debate and led to the development of two schools of grounded theory: the Glaserian version and the Straussian version (Charmaz, 2000). Glaser and Strauss had different perspectives on the technique of data analysis (Charmaz, 2000). Glaser valued and respected the concept of ‘emergence’, which emphasises the importance of comparing and connecting categories and developing theories from the collected data, and stated that Strauss’s procedures were a rigid technique that forced the data into categories (Glaser, 1992).

In grounded theory, the location in time of the literature review also represents a problem, which continues to spark discussion (Dunne, 2011). In their original publication, The Discovery of Grounded Theory, Glaser and Strauss argued over the timing of the literature review (Glaser and Strauss, 1967). They advised against conducting a literature review in the early stages of the research process (Glaser and Strauss, 1967). They assumed that theoretical concepts would be established naturally from the collected data and that this would aid in “the discovery of theory from data” (Glaser and Strauss, 1967, p. 1). They believed that a literature review should be done after the data analysis because this would reduce the likelihood of the contamination of the data (Glaser and Strauss, 1967). Glaser also maintained that conducting a literature review before collecting data wasted time because researchers might not know what literature was related to the area under study (Glaser, 1992). Charmaz (2006) suggests that postponing the literature review can help “to avoid importing preconceived ideas, and imposing them on your work, and it encourages you to articulate your ideas” (p. 165).

92 However, Strauss’s position has changed significantly and he now advocates an early review of the literature (Corbin and Strauss, 2015). Other grounded theorists also insist that, for practical reasons, researchers have to conduct a literature review early to include findings in their study proposals for funding and ethical review purposes (Hallberg, 2010). For this study, the researcher performed a general literature review at an early stage in the study, which enriched the researcher’s understanding of her research topic (Lempert, 2007). The literature review was an ongoing process concurrent with the progress of the study. The researcher also performed a more comprehensive literature review at the analysis stage. She also undertook a literature review when she wrote the discussion chapter.

Constructivist grounded theory is a recent version of grounded theory that was formed by Kathy Charmaz, one of Glaser’s students (Charmaz, 2006). Constructivist grounded theory assesses more than superficial data performance by undertaking situation analysis within a particular condition (Morse et al., 2016). It involves explaining “liminal meanings” and “tacit actions” (Morse et al., 2016, p. 138). In addition, it views results as a construction that provides an understanding of the data, rather than as an objective to discover truth (Charmaz, 2000). Charmaz (2000) maintains that researchers construct theory through their interactions with the research participants. With Bryant, Charmaz emphasised that constructivism happens when people make meaningful words by discussing the meaning of their realities (Bryant and Charmaz, 2007). That means that social reality is determined by human action and how people build meaning (Bryant and Charmaz, 2007).

3.8.2 Selecting constructivist grounded theory Constructivist grounded theory was selected as a research approach for this study. The reason for choosing Charmaz’s constructivist grounded theory was the researcher’s ontological stance, which acknowledges that the social world consists of various realities that are affected by social contexts. The central construct of the research was women’s experience of EBF and other participants’ perspectives on EBF (Charmaz, 2006). By taking an epistemological stance during the interaction with the participants in this study, the researcher understood the participants’ meanings with regard to EBF and how they built their perspectives and understanding of it (Charmaz, 2000). In light of the researcher’s previous experience of breastfeeding and her background, she was able to use probing questions to ask the women to clarify points. The use of probing questions

93 helped the researcher to gain a comprehensive understanding of EBF within the Omani context. This interaction allowed the researcher to form knowledge about EBF with the participants in order to understand their meanings (Charmaz, 2000). Charmaz’s grounded theory was also appropriate for this study because it has a flexible approach that allows the analysis of individuals’ interpretation of experience and permits multiple viewpoints and facts from the participants. As a novice researcher, the researcher needed flexibility in the approach she took. Charmaz (2000) considers that there are many realities in the world, which researchers should construct together with the participants and accept that subjectivity affects them and their lives. As part of this research, the researcher was reacting to a social setting, which reflects the flexibility afforded by qualitative study and grounded theory methods.

Within the Omani context, there are limited and insufficient numbers of research studies that discuss women’s perspectives on EBF, and no published literature has been carried out on the perspectives of breastfeeding women, family members and healthcare professionals. Most of the published research studies are from high-income countries, in which there are different healthcare systems and settings that are possibly not transferable to the Omani context. The constructivist approach helped in developing a conceptual understanding of the research participants with regard to EBF within the Omani context (Bryant and Charmaz, 2007).

Charmaz (2006) recognised the core components of constructivist grounded theory as the following: the simultaneous collection and analysis of data, the conception of codes and categories from the data, constant comparison during data analysis, and memo-writing on identified categories, their properties and connections in order to identify gaps. Other characteristics include theoretical sampling and sensitivity, which empower the researcher to produce theory grounded in the data and not from pre-existing theories (Glaser and Strauss, 1967). The conceptualisation of the data collected in the form of codes and categories assists the researcher to construct a theory (Glaser, 1978). Also relevant is memo-writing, which is “a crucial method in grounded theory because it prompts you to analyse your data and codes early in the research process” (Charmaz, 2014, p. 162). Grounded theory methodology results in the production of a theory (Strauss and Corbin, 1994). That means that the theory created has many conceptual relationships which came from the context of descriptive writing.

94 The following sections regarding research methods refer to the principles of the constructivist grounded theory method applied in this research study. The selection of study sites, such as the referral hospital and health centres, is also illustrated, together with the sampling techniques, how access to the study participants was gained and the recruitment process. The chapter then discusses how the data were collected and analysed. Ethical considerations relating to the research are presented at the end of the chapter.

3.9 Research Methods

3.9.1 Selecting the study sites This study was conducted in the North Batinah Governorate (NBG) of Oman. In total, there are five hospitals and twenty-nine primary healthcare institutions belonging to the MOH in the NBG (NCSI, 2017b). The researcher selected three healthcare institutions across three wilayats in NBG with the intention of reaching women who were planning on exclusively breastfeeding their babies. The researcher also intended to reach the women’s family members and healthcare professionals in order to explore the women’s experiences of EBF and the perspectives of the other participants. The researcher selected one referral hospital, which provides primary, secondary and tertiary care, and two health centres, which offer primary and secondary care to women and their babies. The three healthcare institutions were deemed the most appropriate sites for gaining access to research participants.

The researcher selected the above healthcare institutions as she had to consider certain practical matters, such as the weather, traffic congestion, amount of travel and costs. In addition, the study sites were selected because they were known to the researcher and were close to her place of residence. The researcher previous role was training the nursing students at different maternal units in the selected healthcare institutions. Batinah Governorate is also the second governorate by population size after Muscat Governorate (NCSI, 2018b). Data were collected from the three healthcare institutions, which belong to the MOH in the NBG in Oman. The health centres deliver antenatal and postnatal care services for all the women in Oman. Pregnant women receive services from antenatal clinics in those health centres. During their antenatal care, pregnant women usually receive six appointments, during which healthcare professionals perform blood and urine investigations, as well as sonar and physical examinations. The women also receive health education about risk factors during pregnancy, breastfeeding and nutrition. The

95 healthcare institutions also include a large number of maternal services for women and their babies in NBG, such as birth spacing advice and immunisation services. The referral hospital provides care to women covering the antenatal, intrapartum and postnatal periods. The referral hospital was also chosen in order to reach women who experienced a normal birth. According to annual health statistics from the MOH, the birth rate in Oman is 24 births per 1,000 population (MOH, 2014a). For intrapartum care, women go directly to the referral hospital and stay there for one day if they have a normal birth. After the birth, follow-up appointments continue in the postnatal clinics in the health centres. Women have two follow-up postnatal appointments: one at the second week and another at the sixth week after childbirth. During the visits, midwives assess the woman’s and her baby’s health status, checking if there were any complications after childbirth, advising the woman on breastfeeding, and discussing suitable birth spacing methods with her.

3.9.2 Sampling Research results are dependent on having an appropriate research approach. Selection of the sample is crucial, as it can negatively affect the outcome of the study if insufficient care is taken (Morgan, 2004). Thus, researchers must consider who will answer the research questions (Morgan, 2004). The sample in qualitative research reflects the phenomenon under study, allowing researchers to obtain in-depth and comprehensive data (Miles and Huberman, 1994). The main types of sample used in qualitative research are purposive, convenience, snowball, and theoretical (Morgan, 2004). In grounded theory, non-probability sampling is used at the beginning of a study (Strauss and Corbin, 1998). At the beginning of the data collection, purposive sampling is used and relies on inclusion criteria. Purposive sampling assists in starting the data collection process, whereas theoretical sampling helps to direct the study (Charmaz, 2014). Purposive sampling becomes theoretical, whereby the sampling is specified by the developing theory (Charmaz, 2014). According to Glaser and Strauss (1967), theoretical sampling in grounded theory depends on selecting participants who can give more information, as this helps to develop theory. Thus, the initial sampling technique should identify research participants who meet the inclusion criteria of the study for the concepts to be developed (Given, 2008), and theoretical sampling helps researchers develop a theory (Charmaz, 2000). In this study, both purposive and theoretical sampling techniques were used. Table 3.1 details the inclusion criteria for the research sample.

96 Table 3.1: Inclusion criteria for the participants of the study

Inclusion criteria for postnatal women

• Women aged 18 years and above because they are considered adults and can provide consent for themselves. • Postnatal women who gave birth to a single healthy baby. • Women who breastfed their babies exclusively during hospitalisation (i.e., the infant receives only breast milk, and no other fluids or solids are given except for oral rehydration solution or medication) (WHO, 2003).

Inclusion criteria for family members

• Family members of the same female participants, such as partners (the woman’s husband), mothers (grandmothers) and mothers-in-law.

Inclusion criteria for healthcare professionals

• Registered midwives or nurses working in the study hospital (maternal clinics, labour rooms, postnatal wards, and maternal clinics). • Registered midwives or nurses working in the chosen health centres (maternal clinics).

Purposive sampling Purposive sampling allows researchers to recruit participants with characteristics of interest to their study (Creswell, 2014). It is crucial for researchers to select participants who have experience of the phenomenon under study (Morgan, 2004). For this study, purposive sampling, which is based on inclusion criteria, was used to recruit five postnatal women (Ritchie et al., 2003). Criterion sampling is one type of purposive sampling and includes participants in a study according to specific inclusion criteria (Given, 2008). Criterion sampling works well when the participants have the same experience (Creswell, 1998). This study aimed to recruit postnatal women with different characteristics. For example, to increase the diversity of the sample, women with varying levels of education and different ages, places of residence, working status and experiences of breastfeeding

97 (primigravida and multigravida women) were selected. The researcher deliberately chose different characteristics to obtain various perspectives on EBF.

Theoretical sampling Theoretical sampling is an essential part of the grounded theory method (Glaser, 1965). It is defined as “sampling that is determined by concepts, categories and emerging theory that is grounded in the data” (Cluett and Bluff, 2000, p. 216). It is a way of selecting the sample for a study and of knowing when to stop collecting data (Morgan, 2004). It is also a process of simultaneous data collection and analysis in order to identify developing categories (Charmaz, 2006). This process continues until no more categories are developed from the data (Morgan, 2004). Theoretical sampling is flexible and enables a variety of data to be collected (Glaser and Strauss, 1967). It also permits researchers to follow directions in data (Charmaz, 2000). This flexibility enables researchers to seek other participants for the study as different factors develop (Morgan, 2004). Theoretical sampling attempts to discover categories in order to detect the relations between them, which helps in developing theoretical data. As the research proceeds, simultaneous data collection and analysis generates theoretical data in order to seek participants who can give additional information on issues that arise from the data analysis (Morse et al., 2016). Data collection is then informed by the emerging theory. According to Charmaz (2014), theoretical sampling assists researchers to examine participants who can contribute to developing a theory. Participants are recruited according to their insights and perceptions, contributing to the developing theory and the saturation of the emerged categories (Glaser, 1978). In this study, theoretical sampling was continued until theoretical saturation was reached, when no new theoretical categories were developed from the data (Charmaz, 2006), with the guidance of the supervisory team.

3.9.3 Sample size According to Charmaz (2014), in grounded theory, the number of participants depends on the research questions, the researcher’s experience of research, how the researcher constructs the analysis and the analytical level of the researcher. Therefore, the exact size of the sample cannot be determined before conducting the initial data collection and analysis. Instead, it is advised that the sample size in grounded theory is developed inductively until theoretical saturation occurs (Guest et al., 2006). In grounded theory, the iterative method encourages researchers to develop interview questions and skills (Charmaz, 2014). For a research project that seeks to know general perceptions and

98 experiences among a group of relatively similar individuals, twelve interviews should be adequate to reach saturation (Guest et al., 2006). A sample of between twenty and thirty participants is generally adequate for achieving theoretical saturation in grounded theory (Morse, 2000). In the current research, the researcher added participants until theoretical saturation was obtained and nothing new was emerging from the data.

3.10 Data Collection Methods

Interviews and observations remain the principal methods of data collection in qualitative research (Walsh and Baker, 2004). In the current study, interviews and observations were used to collect the data. The primary purpose of interviews is to explore the meaning of an experience (Walsh and Baker, 2004). The decision to use interviews in this study was made in order to obtain rich data and descriptions of different perspectives on EBF. A face-to-face interview is considered an appropriate method of collecting sensitive or personal data (Creswell, 1998). Consequently, this method helped in obtaining useful information about EBF from the women who participated in this study (Berg, 2009). Interview and observation techniques are both considered suitable in grounded theory (Hall and Callery, 2001). Thus, the decision was made in this study to use interviews as the primary source of data in order to clarify the participants’ points of view in their own words (Silverman, 2013). Data collected using the interview method give a real insight into people’s experiences (Silverman, 2013). Interviews permitted the present researcher to know the participants’ perspectives of EBF from their real experiences and in their own words.

3.10.1 Semi-structured interviews Generally, there are four forms of interview that are used in research studies: structured, semi-structured, unstructured, and focus group discussions (Al Saawi, 2014). Structured interviews are planned interviews in which the interview questions are written before the researcher conducts the interview (Al Saawi, 2014). However, researchers using this type of interview do not obtain in-depth or comprehensive data from research participants (Al Saawi, 2014). Unstructured interviews are usually used in grounded theory methodology because they are a useful method of identifying a problem (Charmaz, 2006). Interviews also allow researchers to view participants holistically by encouraging them to talk spontaneously and freely. This notion is supported by Wimpenny and Gass (2000), who mention that unstructured interviews are considered the most reliable means of collecting

99 personal and private data from participants. Researchers use in-depth interviews to study specific topics about the experience and understanding of the participants (Charmaz, 2014).

Although there are many advantages to using unstructured interviews in grounded theory, the researcher decided to use semi-structured interviews for this study. As a novice in research, the researcher felt that semi-structured interviews would allow her to use probing questions in order to elicit comprehensive data from the research participants. Semi-structured interviews allow some flexibility for researchers in asking probing queries (Berg, 2009). Grounded theory methods allow flexibility when collecting data because they encourage researchers to follow up on what is happening (Charmaz, 2014). Charmaz (2006, p. 26) stated that the structure of an in-depth interview varies from “a loosely guided exploration of topics to semi-structured focused questions”. A semi- structured interview allows researchers to appear capable during the interview; it also provides reliable qualitative data (Berg, 2009). Thus, it was deemed appropriate to use a semi-structured interview technique in this study.

In this study, semi-structured in-depth face-to-face interviews were the most significant method of collecting data regarding the participants’ perspectives and experiences of EBF. According to Charmaz (2006), listening to participants telling their stories and talking about their experiences is very important during the early stages of grounded theory research to explore issues. Therefore, at the initial stage of data collection, semi- structured interviews were conducted with five postnatal women who met the inclusion criteria because little is known around this phenomenon in Oman. The initial analysis of the data indicated the need to recruit additional women to the study, as well as family members of the women participants and healthcare professionals. The researcher intended to explore the women’s experiences and perspectives related to EBF from those initial interviews. According to Charmaz (2014), flexibility within an interview is essential when exploring new ideas about the phenomenon under study. Using semi-structured interviews allows some flexibility; for example, they allow researchers to follow issues that relate to the research question and explore and clarify comments made by the participants (McIntosh and Morse, 2015). Therefore, semi-structured interviews allow researchers to ask questions, in the same way, in greater depth to explore the issues under study (McIntosh and Morse, 2015).

100 Semi-structured interviews with postnatal women Eleven postnatal women participated in the interviews. All the women participants in the interviews agreed to continue follow-up interviews for four months or until they stopped breastfeeding, whichever came first. The interviews were conducted on the seventh day, and at one, two, three, and four months postnatally (see Appendix 4 for a sample of an interview). Before each interview, the researcher called the woman to confirm if she was still interested in participating in the study. The researcher conducted interviews with three women who were breastfeeding until the end of the data collection period (four months) and thus, in total, the researcher conducted five interviews for each of those three women. The earliest point at which women who participated in the study stopped breastfeeding was eight weeks after childbirth and thus the researcher conducted three interviews with the two women who stopped breastfeeding after two months. Four interviews were conducted with two women who stopped breastfeeding in the third month, and five interviews were conducted with four women who stopped breastfeeding in the fourth month after birth. The researcher conducted a final interview with all the women who stopped breastfeeding to learn the reason behind breastfeeding cessation. The timings of the interviews held with the women and breastfeeding cessation is illustrated in Appendix 5. In total, fifty-seven interviews were conducted with postnatal women: fifty-five interviews were conducted in the women’s homes and two in a meeting room at the health centre during the women’s follow-up appointments.

Semi-structured interviews with family members Each of the family members who participated was interviewed once. In total, five interviews were conducted in family members’ homes. Those interviews were conducted after the interviews with the postnatal women were completed.

Semi-structured interviews with healthcare professionals One interview was conducted with each of the healthcare professionals who participated in the interviews. In total, seven interviews were conducted: five interviews were performed with healthcare professionals (midwives and nurses) in the doctor’s office at the chosen hospital, and two interviews with managers from the maternity unit (midwives) were conducted in their offices at the hospital, in accordance with their request. These interviews were conducted when the healthcare professionals had been on a short amount of leave.

101 3.10.2 Topic guide Before starting the interviews with breastfeeding women, an initial interview topic guide was developed (see Appendix 6). The researcher discussed the topic guide with the supervisory team and all agreed the questions to include in the topic guide. The topic guide was used to ensure that all the relevant questions were covered to meet the objectives of the study. The interview guide was prepared following Charmaz’s (2000) recommendation to use open-ended questions, as these would help the researcher discuss concepts with participants as they developed (Patton, 2002). Discussions with the participants allowed the researcher to explore their views on their experience of EBF. After the first few interviews with postnatal women, it was clear that questions needed to be added to the topic guide to understand further issues that were emerging from the conversations and the guide was amended accordingly (see Appendix 7).

Wimpenny and Gass (2000) indicated that analysis in grounded theory affects the questions that will be asked. Thus, the questions and method of data collection can be amended after the initial analysis of the data. In this study, the interview schedule was revised by the supervisory team and the researcher after the initial constant comparative analysis and the emergence of categories. After the initial data analysis, it became clear that it was necessary to interview family members and healthcare professionals; other topic guides were then used (see Appendices 8 and 9). A decision to conduct clinical observations was also made with the approval of the supervisory team. For this study, the topic guides and observational data collection sheet were developed before the initial data collection. The researcher obtained ethical approval from UREC in the UK and RERAC in Oman; these documents were further developed as required.

3.10.3 Data collection process Creswell (2014) encourages researchers to create a comfortable environment and develop a rapport and connection with participants to obtain detailed views that will help ensure the quality of the information obtained. In this study, the venue for the interviews was decided by the participants and the majority chose to be interviewed in their home. Charmaz (2014) suggests that the researcher asks initial, open-ended, intermediate and closing questions. Open-ended questions indicate that the researcher is willing to listen to the research participant, which leads to obtaining rich information (Farrell, 2016). In addition, probing questions are used to clarify points and obtain further information about responses that might not have been clear. As suggested by Charmaz (2014), detail-

102 oriented enquiries, such as ‘what’ and ‘where’ questions, were used in this study. Elaboration probes were also used, such as asking for further clarification and examples (Walsh and Baker, 2004). According to Glaser (2001), probing questions help the researcher to obtain more in-depth information from research participants. Probing questions also provide the opportunity to explore sensitive areas and help study participants with the recall of information (Swanson and Holton, 2005). In this study, more specific questions related to EBF were utilised, which expanded the data and facilitated theoretical sampling by indicating who among the women participants might provide additional information in order to saturate the categories (Charmaz, 2006; Morse et al., 2016). For example, an opening question was asked, such as: ‘How did you experience breastfeeding?’ Intermediate questions were more focused, such as: ‘Please, can you explain to me why you think breastfeeding is difficult?’ Then a final question (designed to draw the interview to a close) was posed, such as: ‘Is there anything you would like to tell me about your experience of breastfeeding?’ The ending questions helped the study participants to talk about their feelings regarding their breastfeeding experiences. The length of the interviews depended on how much the participants had to say about their experiences. Each interview took around 40–70 minutes.

All the interviews in this study were audio-recorded using a digital recorder. All the participants were informed in advance about the use of recording equipment during the interviews to ensure the accuracy of the data obtained (Rabionet, 2011). All the participants consented to the researcher using a digital tape recorder. Audio recording enabled the researcher to focus on the participants’ responses and conversations, rather than writing notes which might have distracted the researcher from listening to participants’ answers. Field notes were made after each interview regarding the issues that emerged and to enable reflection on the sessions. The researcher tried to write memos in her notebook as soon as possible after she completed the data collection process. For example, uncertainty about continuing breastfeeding made many of the women participants feel sad due to their connecting breastfeeding with motherhood. The researcher made reflective notes on how Omani community expectations of breastfeeding influenced breastfeeding practice in Oman.

Reflection on the challenges of interviewing The interview sites presented no distractions for the participants of this study and, therefore, did not affect the quality of the interviews. The places chosen were comfortable

103 and quiet for interviews. However, while interviewing two women during their follow- up appointments in the health centre, some interruptions from nurses who wanted to use the meeting room were experienced. However, the researcher reassured the nurses that the interviews would be finished within the time allocated and the researcher did not rush the interviews. During some of the interviews that were conducted at the women’s homes, the researcher faced interruptions from children who were screaming and playing with the voice recorder during the interviews, so the researcher asked the women if it would be acceptable to move to a quiet area and not allow the children to enter the room during the interview. The women considered and accepted the researcher’s request and asked the children to play in another room. Before leaving the home, the researcher apologised again to the women for not allowing their children to be in the room during the interview.

3.10.4 Transcription process Transcription is the process during which a researcher converts speech into written text, or a transcript (Lapadat and Lindsay, 1999). Verbatim transcription should be carried out as soon as the interview is completed in order to allow researchers to familiarise themselves with the data, as this helps in data analysis (Halcomb and Davidson, 2006). The philosophical stance of grounded theory encourages researchers to interact with the data obtained in order to understand the material and to be as close as possible to the data, which is helped by the transcription process (Halcomb and Davidson, 2006). Charmaz (2014, p. 99) argued that studying data from transcripts exposes more of the “nuances of your research participants’ language and meanings”. She emphasised the importance of transcribing as soon as data collection has finished so that researchers will be close to the participants’ beliefs and feelings (Charmaz, 2014). Verbatim transcription of data enables researchers to understand data more fully (Oliver et al., 2005). Thus, researchers need to transcribe all the collected data as soon as possible in order to understand their data and to be close to the information they have collected (Wellard and McKenna, 2001). As a novice researcher, it was important for the current researcher to record all the interviews in this study in order not to miss any beneficial information from the participants, an approach that is aligned with the recommendations of Birks and Mills (2015).

Listening to the recordings helped the researcher to evaluate the way the interviews were conducted and assisted in identifying questions that needed more probing (Easton et al., 2000). For example, when listening to the first interview recording, the researcher recognised that she was talking quickly. The researcher also noticed that she did not probe

104 some areas of the woman’s experience of breastfeeding. Therefore, she made a note in the field notebook to seek clarification in the next interview with the same woman. The researcher transcribed all the interviews in Arabic first because all the participants spoke in Arabic during the interviews. She then translated the transcripts into English, which helped in understanding the meanings of each woman’s breastfeeding experience and in order to share these transcripts with the supervisory team. Novice researchers need to transcribe their tapes because this enhances their immersion and involvement in their collected data (Wellard and McKenna, 2001).

However, there were some difficulties during the transcription of the interviews due to the way the study participants talked, which affected the clarity of the recording (Oliver et al., 2005). Some participants talked quickly and it was difficult to understand what they said. Nevertheless, the researcher listened to the recordings several times to try to understand their words (Oliver et al., 2005). The transcription process was time- consuming, each transcription taking approximately 8–12 hours; however, the advantages were more significant than the disadvantages as this helped to understand the data collected (Halcomb and Davidson, 2006).

3.10.5 Translation process This research study examined the experiences of women who were breastfeeding in Oman, where meanings of EBF were constructed from social interaction. Language performs a fundamental function in shaping the meanings of the experiences of research participants (Van Nes et al., 2010). Data from the women participants were obtained in Arabic; thus, it was vital to translate the transcripts into English in order to analyse the data with the supervisory team and to include extracts from the interviews in the thesis and in any publications. Interviews were conducted in Arabic spoken with an Omani accent, which differs from one participant to another, depending on their place of residence or the geographical location of the participants. The participants had been recruited from three different wilayats in NBG in Oman. It was noticed that there were variations in the Omani accents and the participants used some words that were not clear to the researcher, particularly those participants who lived on the border with the UAE. Determining which term would provide the exact and real meaning of the participants’ words was challenging and might have affected the trustworthiness of the study (Birbili, 2000). Thus, to ensure the trustworthiness of the study, it was important to ask the study participants to interpret the meaning of some terms they used during the interviews. For

105 example, the meaning of “Al-shatoha” was asked (it means a baby’s bed), “Al-shbria” (bed) and “banhi” (I will go). During the translation of the Arabic transcripts, the researcher gained a rich explanation of the participants’ meanings of EBF. An Arabic– English dictionary was also used to identify a good equivalent of the participants’ expressions (Baalbaki, 1996). The dictionary assisted in maintaining the women’s stories, meanings and experiences during the translation process.

It is well known that translators can have an impact on the research process and findings; thus, the researcher translated all the transcripts herself (Squires, 2008). The reason for not choosing other translators was that the researcher wanted to understand the collected data and she felt that an external translator might limit the interaction with the material; thus, she undertook the translation of all the transcripts herself. Professional translators can give the literal meaning of spoken conversation by using exact translations; however, they may not understand the related meanings of the participants’ words. In addition, translating in Oman is costly. Thus, the researcher thought she would be able to translate the transcripts herself because she speaks a similar language. According to Van Nes et al. (2010), if researchers speak a similar language to the participants, this reduces language diversity during the process of data collection and analysis. The translation process helped increase the researcher’s immersion in the data; it also helped her to interact with the collected data and understand the words spoken by the participants in this study.

In this study, the researcher collected, transcribed and translated the interviews personally to understand the participants’ meanings regarding EBF and to increase the credibility of the study. Twinn (1997) stated that having the same researcher(s) carry out the interviews and transcribe and translate the collected information increases the credibility of a research study.

3.10.6 Non-participant observations The initial analysis of the data suggested that additional data needed to be collected to examine the broader context of EBF. For example, in the first interviews, the women reported a lack of support and a negative attitude from healthcare professionals in the healthcare institutions selected. Thus, non-participant observations were conducted with postnatal women and healthcare professionals to gain an understanding of the problems and concerns revealed by the women participants during the early interviews (see Appendix 10 for a sample of an observation). For the clinical observations, data were

106 gathered using an observation guide (see Appendix 11). Marshall and Rossman (1989, p. 79) defined observation as “the systematic description of events, behaviours, and artefacts in the social setting chosen for study”. The purpose of the clinical observations in this study was to observe how healthcare professionals supported breastfeeding women in the healthcare institutions selected. The observation technique is a useful aid for researchers wishing to gain a thorough understanding of what is occurring (Parke and Griffiths, 2008).

Moore and Savage (2002) proposed observation as a useful method of collecting data from participants and in helping researchers to learn how participants interact within their social circumstances. It also helps researchers to monitor verbal and non-verbal interactions (Kirkham, 1989). Through observation, researchers can watch people in their natural environment and observe their interactions and behaviours (Kirkham, 1989; Parke and Griffiths, 2008). Observation also allows researchers to use their senses to describe present conditions and provide written notes of the phenomenon under study (Wolfinger, 2002). In this study, observation enabled the researcher to record the interaction and communication between women participants and healthcare professionals. Some researchers prefer to use observational methods instead of interviews because they want to study events that are occurring naturally (Dingwall, 1997). Observation provides researchers with the opportunity to acquire valuable and precious information by analysing participants’ meanings in their normal context (Becker and Geer, 1957). Observations also afford researchers a clear understanding of what is being observed (Charmaz, 1990). According to Liu and Maitlis (2010), observation is used to explain and understand an experience under study; researchers enter the observational area only to observe what the participants are doing and separate themselves from the activities being studied. Non-participant observation is utilised with other data collection methods, such as interviews, and can contribute to a deep understanding of a situation that cannot be explored by other methods (Liu and Maitlis, 2010). Thus, non-participant observation was used in this study to confirm what women and healthcare professionals had stated in the interviews without interfering with their usual activities. For instance, the researcher observed what the women had reported earlier about the behaviour of the healthcare professionals postnatally and the ways they promoted breastfeeding in the healthcare institutions selected.

107 In this study, field notes were taken during the clinical observations about the support provided to breastfeeding women by healthcare professionals, their interaction and the way they communicated. According to Creswell (2014), observation is vital to understanding social activities, such as the interactions between research participants. Field notes for this study were written on the observation template immediately after the observations while they were fresh in the memory of the researcher. Each woman and healthcare professional participant was observed for 2–3 hours. In the maternity units, the researcher placed herself in one corner of the room to watch the reactions and attitudes of the participants. Furthermore, the researcher observed postnatal women from the time they arrived until they left labour room area. The researcher observed all the women’s interactions with the healthcare professionals. The researcher also sat with the women participants in the waiting area of the maternal clinic and observed their behaviour.

Although observations have many advantages in a research study, there are still some matters that need to be considered. As a novice researcher, the researcher found it difficult during the first two observations to separate what she observed from her own interpretation. It was difficult for the researcher to be a non-participant because she is a nurse. Initially, the researcher was asking questions of the healthcare professionals during the observations. After contact with the supervisory team, it was decided not to include these two observations in the study. Instead, the researcher placed herself in one corner of the room in which the clinical observation was conducted in order to watch the behaviour and reactions of the participants. The researcher also followed each woman and observed the woman’s interaction with the healthcare professionals. The observation sheet was updated after the first two observations, with the approval of the supervisory team, to enable the researcher to observe the participants in a more focused way. Space to add the time and date was also allocated on the form, with scope for the researcher to add her reflections. Writing a reflection allowed the researcher to record how a particular situation occurred during the clinical observation and to write about the researcher’s feelings and interpretations (Fitzpatrick and Boulton, 1996). An observation guide empowers researchers to direct their observations towards particular events that are taking place in a naturalistic setting (Pretzlik, 1994). Clinical observation was carried out in this study in order to understand how healthcare professionals support breastfeeding practice, so it was necessary to develop a systematic form to observe the attitude of the healthcare professionals, how they supported breastfeeding women and the interaction between them

108 and the women participants. The updated form was more detailed and structured, which helped the researcher to focus her observations (see Appendix 12). This approach is appropriate in situations in which researchers wish to observe specific activities for a long time, or in repeated observations (Kawulich, 2012). Therefore, as a novice researcher, the researcher found an observation guide beneficial because it assisted her in being more focused while observing participants’ interactions and behaviours in their social environment (Cohen and Crabtree, 2006).

One of the limitations of observations is the presence of the researcher in the observational area, as this may have some effect on participants’ performance and behaviour (Mulhall, 2003). This is known as the Hawthorne effect and is an obvious drawback of observations (Mulhall, 2003); it is also known as the observer effect (Monahan and Fisher, 2010), whereby individuals alter their behaviour in response to their knowledge of being observed and this can impair the honesty of a research study (Salkind, 2010). For example, during the interviews, women reported that healthcare professionals dealt negatively with them; however, the researcher did not witness such negativity during the observations. Thus, it was possible that the healthcare professionals did not show typical behaviour because of the presence of the researcher, despite the researcher having explained the aim of conducting the observations. In this study, data were collected from the participants until no new information developed from the clinical observations, and a comprehensive picture of the interaction between the women and the healthcare professionals had been obtained (Casey, 2006).

3.11 Data Analysis in Constructivist Grounded Theory

Data analysis is a systematic process and starts as soon as the researcher has collected the data (Urquhart, 2012). The analysis involves arranging the data, coding them, minimising the codes into themes and, finally, presenting the findings (Creswell, 2014). The analysis continues with the identification of categories and the relationships between them until no new conceptualisations appear (Urquhart, 2012). Researchers have the intention of looking for concepts and categories that appear from their data, rather than forcing categories that were identified previously. In this study, data transcription allowed the researcher to make notes on how the women talked during the interviews, which was necessary for data interpretation (Bailey, 2008). For example, when the researcher listened to the recordings, she understood from the women participants’ tone of voice that

109 they were not happy with the healthcare professionals. Reading each transcript several times helped the researcher to become immersed in and understand the data (Streubert Speziale and Carpenter, 2003), which enabled her to understand the women’s experience of EBF. When the researcher was reading the transcripts of interviews and the clinical observations, she talked to herself and with the data and asked questions such as ‘why?’, ‘how?’ and ‘what?’. These activities helped to better understand the women’s experience of EBF.

In this study, the principles of constructivist grounded theory were applied to analyse the data, which include data coding, constant comparison, memo-writing, and data saturation (Charmaz, 2014). Three stages of the coding process recommended by Charmaz (2014) were used: initial coding, focused coding and theoretical coding. Charmaz’s (2006) process of data analysis, which involves initial and focused coding, is comparable with that of Glaser and Strauss (1967), but Charmaz’s (2000) analysis includes further flexibility in the coding process, which is suitable for interpreting data. Grounded theory coding is a very useful tool that enables researchers to understand what is happening in the data (Charmaz, 2014). During the coding process, constant comparison and memo- writing are essential steps to shift analysis from the descriptive to the conceptual level (Charmaz, 2014).

3.11.1 Initial coding Open coding is defined as “coding the data every way possible” (Glaser, 1978, p. 56). Initial coding is the first step in the coding process and enables researchers to form a link between collecting data and developing a theory in order to understand those data (Charmaz, 2014). This first step involves analysing each sentence line by line in order to explain participants’ experiences by allocating a code or label (Fassinger, 2005). Through the initial coding, researchers define what is happening in the data and try to understand what it means (Charmaz, 2014). Glaser’s (1978) query for analysis, ‘What is happening here?’, is an essential question at this stage. During the initial coding for this study, the researcher performed a line-by-line analysis of each sentence for all the transcripts. This process helped the researcher to understand what was happening in the women’s accounts of their experiences of breastfeeding in each line of data and what theoretical ideas this suggested (Charmaz, 2014). Gerunds (‘-ing’) were used, as advised by Charmaz (2014), during the initial labelling of the codes to promote theoretical sensitivity in the study. The initial codes were then grouped into larger codes in order to produce a theory (Urquhart,

110 2012). Line-by-line coding encourages researchers to engage actively with their data and to see data from new viewpoints (Charmaz, 2014).

In this study, initial coding also helped the researcher to recognise gaps in the initial phase, which is, according to Charmaz (2014), a segment of the principle of grounded theory. Applying line-by-line coding to the transcripts of the initial interviews helped to identify new ideas from the data, which the researcher followed up in subsequent interviews (Charmaz, 2014). For example, the initial process of the analysis revealed the need to collect data from non-participant observation and to conduct more interviews with other women, their family members and healthcare professionals. In addition, it is essential that different people take part in coding with the researcher during the initial stage (Charmaz, 2014). Thus, the researcher sent the initial coding of the first five interviews to the supervisory team for review. The supervisors noted and commented on the codes and suggested reviewing some of the code names. The initial coding produced over 220 codes, which needed to be grouped and structured.

The researcher also utilised in-vivo codes from the participants’ words in this study in order to generate codes which were grounded in the data. In-vivo codes use participants’ own words about their meanings and experiences (Charmaz, 2000). According to Charmaz (2014), novice researchers may find that they rely entirely on in-vivo codes. However, the researcher was aware of this limitation and avoided overuse of in-vivo codes during the coding process. For instance, ‘breastfeeding is a natural process’ was an expression used by the breastfeeding women, which remained a tentative code until it was upgraded to the level of a sub-category. In-vivo codes help researchers to remain familiar with the data by using the participants’ own words to develop codes that are grounded in the data (Charmaz, 2014). Using in-vivo codes gives more value to the meaning of participants’ words. Table 3.2 gives an example of the initial coding process.

111 Table 3.2: Example of initial coding

Supporting data Initial coding

“There are many benefits for breastfeeding for baby, it Knowing the health protects the baby from infections, it increase baby’s benefits of breast milk. immunity.” (Star, MG: 4 months, 2nd Interview)

“I learned breastfeeding from my mother and my sisters, Learning breastfeeding all women are breastfeeding in my family.” (Muluk, from the older generation. MG: 4 months, 1st Interview)

“All women in my family are breastfeeding and I have to Breastfeeding is a social do the same, I have to do like them, it is usual practice.” practice. (Moon, PG: 3 months, 2nd Interview)

3.11.2 Focused coding The second step of the coding process comes when coding is limited only to those categories that relate to the core category (Glaser, 1978). This process includes grouping and arranging the initial codes into the main categories identified using a constant comparison approach (Charmaz, 2014). The approach involves determining the most significant codes and assigning unique labels to them (Charmaz, 2014). The categories identified could be important themes that reflect the concepts included in them. This process helps the researcher to organise and integrate large parts of the data. In focused coding, the researcher concentrates on the most useful and often-repeated initial codes (Charmaz, 2008). After that, the researcher examines the categories against extensive data for similarities and variations to help in synthesising categories together using memos at this stage (Charmaz, 2014). A constant comparison approach upgrades and raises these codes to a conceptual level (Lempert, 2007). By this stage, the researcher is able to determine the most suitable concepts and identify which categories needed to be refined.

In this research, the main categories were developed as the analysis process continued. For example, the category Breastfeeding Expectations appeared from some of the initial codes, such as ‘I knew that I would breastfeed’; ‘breastfeeding is the breast’s function’; ‘I saw women in my family breastfeeding’; ‘breastfeeding is a natural process’; and ‘breastfeeding will happen’. During this period, the categories that emerged were compared in order to bring together all the data that described the experience of

112 breastfeeding women into three main categories. The findings chapters refer to the three main categories and their sub-categories identified in the study. The constant comparison process and memo-writing were used to help identify the three main categories and their related sub-categories. The categories and sub-categories and their properties were established by conducting several constant comparisons for each participant. This process included comparing and grouping the developed codes, comparing them with the emerging three categories and comparing the data from different interviews and clinical observations. By making constant comparisons, the data in the interviews and the clinical observations were compared. The process involved comparing the codes and grouping them and then a comparison of the codes with the categories. The researcher also compared the perspectives and experiences of different participants and data from the same participant at different points of an interview and observation. Table 3.3 provides an example of the initial and focused coding processes.

Table 3.3: Example of focused coding Data from the women’s interviews Initial coding Focused coding

“I saw all the women in my family I saw women in my breastfeeding their baby, so I know about family breastfeeding, and I knew that I would breastfeeding. breastfeed as well because all the women were breastfeeding my family or other I knew that I would families.” (Noor, PG: 2 months, 1st breastfeed. Interview)

Breastfeeding “Breastfeeding is gold and a gift from Breastfeeding is Expectations Allah who created the breasts for feeding, breast function. so I wanted to breastfeed my baby because breastfeeding is the function of the breast.” (Muluk, MG: 4 months, 2nd Interview) “Breastfeeding is natural, and it is a Breastfeeding is a natural process. I thought that I do not natural process. need to learn how to breastfeed because I knew that it is natural process and will Breastfeeding will happen.” (Anwar, PG: continued BF happen. more than 4 months, 1st Interview)

113 3.11.3 Theoretical coding According to Charmaz (2014), theoretical coding helps theorise data and concentrate on codes that will help the researcher tell a logical story of the phenomenon under study. This makes complete sense if the researcher understands that theories are constructs (Urquhart, 2012). In this final step, the links between the three main categories that were developed during the focused coding were examined. This step helps researchers to synthesise and move their analytical account in a theoretical way and direction (Charmaz, 2014). Theoretical coding was developed in this research to determine the core category and its connection with the three main categories. Theoretical coding was also developed to determine theory and its linkage with the core category. According to Rintala et al. (2014), the core category should remain abstract, commonly appear in the data, and be constant with the data. A core category is necessary to integrate and combine the categories that emerge into a conceptual framework or theory grounded in the data and defines the theoretical framework of the study (Hallberg, 2006). As a novice researcher, the researcher found it challenging to discover the link between the main three categories. It was also challenging to identify the linkage between the core category and the theory. However, reflecting upon the data in order to find a connection between them by developing a number of diagrams and concept maps was helpful. The researcher was then able to identify linkage between the three main categories. The researcher named the core category ‘Navigating the Reality of Breastfeeding’. She was also able to find linkage between the core category and the theory, which led to the emergence of a theory she called ‘Resilience: The Power to Breastfeed’.

3.12 Theoretical Sensitivity

Theoretical sensitivity is a vital instrument in the grounded theory method (Glaser, 1978). Theoretical sensitivity depends on the ability of the researcher to extract elements from the data that have significance for the emerging theory (Birks and Mills, 2015). It also depends on the researcher’s skill in asking questions and giving meaning to the data in the analytical plane. It is necessary for researchers to ensure that their theory is grounded in their data by understanding the data and knowing how to interpret them. Glaser (2004) insisted that researchers maintain their analytical position by entering the study environment with as few predetermined notions as possible. This enables researchers to be open, which permits the emergence of multiple views from the participants. Glaser

114 (1978) also highlighted the importance of researchers engaging with their data. When researchers engage with their data and select relevant issues and situations, theoretical sensitivity occurs (Strauss and Corbin, 1998). Researchers should also interact with their data by looking at the similarities and dissimilarities between each theme or concept that emerges (Strauss and Corbin, 1998).

Strauss and Corbin (1998) asserted that it is vital for researchers to draw on resources in order to develop insight into their studies, such as the professional and personal experiences of the researchers themselves and the current literature. It is argued that the experiences of researchers help inform data analysis because their experience in a specific area allows them to understand how things work (Corbin and Strauss, 2014). The literature provides researchers with relevant information about their study and predetermined notions. However, Glaser did not accept that researchers should have predetermined notions prior to the data collection and analysis process (Charmaz, 2006). The value and importance of theoretical sensitivity are confirmed in affording meaning to data and decreasing researchers’ biases. Consequently, according to Charmaz (2014), theoretical sensitivity is a fundamental part of a theoretical sampling process and the simultaneous collection and analysis of data.

In this study, the researcher demonstrated theoretical sensitivity at various stages. For example, a general literature review was performed at four levels: at an early stage of the study, an ongoing literature review concurrent with the progress of the study, at the analysis stage, and when she wrote the discussion chapter. Moreover, theoretical sensitivity was considered during the data collection process as the researcher spent a long time listening to the participants’ experiences and stories of EBF. The researcher also made sure that the codes came from the participants’ words. For example, when developing the initial codes, the researcher returned to both the Arabic and English transcripts several times to ensure that the codes came from the women’s and other participants’ words. The supervisory team also themed some of the interviews.

Glaser maintained that theoretical sensitivity is achieved by immersion in the data (Walker and Myrick, 2006). Throughout the analysis process in this study, and during the initial coding in particular, a constant comparison approach helped the researcher to stay close to the data. The researcher was trying to understand the relationships between the data by reflecting on the emerging codes. However, the researcher was aware of the effect of her professional knowledge and personal experience of EBF on the data collection and

115 analysis. According to Glaser and Holton (2004), the effect of predetermined notions is unavoidable. As a woman who had experienced breastfeeding and being part of Omani culture assisted the researcher in developing insights in connection with breastfeeding practice in the study context. Consequently, the researcher was able to understand the experiences of breastfeeding from the participants’ point of view as a mother and as a researcher by asking more probing questions to gain a comprehensive picture of EBF. The researcher did not include her perspective on EBF as she maintained reflective records about her perceptions during the interviews and observations; her perceptions did not affect the analysis and the truth of data was maintained. Theoretical sensitivity appears when researchers’ understand their data and their interpretation of them (Corbin and Strauss, 1990).

3.13 Memo-Writing

The notion of generating theoretical memos was introduced by Glaser (Glaser, 1978) and many researchers value this practice because it allows them space to think creatively around their data (Urquhart, 2012). Glaser (1978, p. 83) described ‘memoing’ as the “bedrock of theory generation”. Memoing is a continuous process for grounded theorists, from the early phases of planning a study until they accomplish their research (Birks and Mills, 2015). Charmaz (2014) emphasised the importance of writing memos as an activity through which researchers actively interact with their data. In this study, memos were written in a dedicated notebook during the process of data collection and analysis and continued throughout the writing-up stage. The process helps researchers to develop ideas about their data and decide the next data to be collected (Charmaz, 2014). Therefore, memo-writing empowers researchers to build categories which are then joined to produce a theory (Strauss and Corbin, 1998).

For this study, memos were written in the researcher’s notebook as soon as possible after the data collection process was completed. The memos were arranged according to the date the data were collected and labelled using the pseudonyms given to the participants (see section 3.16.3). Memoing helped the researcher to decide the subsequent sampling step; for example, whether the researcher needed to include working women or women with previous experience of EBF. When she first began writing memos, the researcher wrote about her experience during the phases of data collection and analysis and the challenges she faced, particularly during the early stage of data collection, such as the

116 long travel distances and the hot and humid weather. Then the researcher wrote about her opinions, feelings and thoughts about women’s experiences of EBF, which helped her to understand the women’s accounts and the perspectives of the other participants on EBF. This step helped the researcher to develop the properties of the emerging categories. Memoing also helped in acknowledging the researcher’s presumptions and grounding the results in the data (Charmaz, 2014). After writing a few memos on women’s experiences with EBF, the researcher’s notes became more intensive and focused upon the developed codes. The two steps of comparing data and memoing provide researchers with the possibility of moving their records from a descriptive to an analytic standard (Green and Thorogood, 2013). Furthermore, memoing helped the current researcher to investigate, with the participants, the concepts that emerged. For example, when ‘lack of professional support’ emerged from the interviews, this concept was discussed with the next women participants and other participants in the study (Box 3.1).

117 During interviews with the women when I was discussing the support that they received while breastfeeding. I was talking with the women about how their mother supported them with first breastfeeding challenges. Many women participants said to me when told about their mother’s support “you know, you know what I mean, you are a mother”. This statement showed that women connected themselves and me as a mother and an Omani woman who is living in the same context. They expected that I understood what they said because they thought that we were sharing the same social and cultural practice of breastfeeding.

During interviews, the women talked about their feeling on the support provided by their family members and the healthcare professionals. When I talked about their mothers’ support, they said that they appreciated their family support, but I felt that their facial expression showed emotional upset. Besides, they used the word like “robot” to describe the way how the midwives dealt with them. The word “robot” indicated that women had a negative feeling towards healthcare professionals. For me, this meant that the women needed more support, not only from their mothers but healthcare professionals. I also found that women were ready to receive support from healthcare providers to overcome their difficulties. It also meant that women trusted me when they were expressing their feelings.

During the observations, I observed how the women were following the instruction of grandmothers on breastfeeding. Also, the healthcare professionals were not interfering with the grandmother’s instruction. This position of grandmothers indicated the valuable role of grandmothers on supporting the women during breastfeeding within the Omani culture.

Box 3.1: Memos interpreting data on breastfeeding support within the Omani context

3.14 Theoretical Saturation

Data saturation refers to “the point at which gathering more data about a theoretical category reveals no new properties nor yields any further theoretical insights about the emerging grounded theory” (Charmaz, 2014, p. 345). The categories that emerge are strong when researchers find no new properties emerging from their data (Glaser, 1978).

118 For this study, collecting data from the study participants continued until data saturation was achieved. The researcher knew that the saturation point had been reached when she noticed that the same concepts continually appeared among the data. Theoretical saturation is the point in coding at which researchers find no new codes appearing in the data (Urquhart, 2012). Saturation is achieved when the concepts could be explained by comparing the research participants’ experiences (Charmaz, 2014). For example, the researcher compared the decisions to breastfeed between multigravida and primigravida women. The researcher also considered the level of education and the women’s ages in their decisions to breastfeed and the same concept appeared; therefore, she knew that the data in this concept were saturated. In this study, the theoretical sampling process was completed when all the properties of the derived core category and the three main categories had been explained and no new concepts were produced (Creswell, 2014). Theoretical saturation for the core and main categories in this study was achieved after the researcher analysed interview number 37 with the women participants. It was difficult for the researcher as a novice researcher to know when theoretical saturation was reached, but regular discussion with the supervisory team and writing memos helped her to recognise it.

3.15 Data Management

In the initial stage of the data analysis, NVivo qualitative data software (version 11) was utilised to split and fragment the data and organise them according to the codes developed for all the participants. An example of initial coding with NVivo software is given in Appendix 13. As a novice researcher, the researcher found that NVivo software was of great help in dealing with large quantities of data and in saving time (Dainty et al., 2000). The software also helped the researcher to collect and group all the related descriptions within a code. Coding using NVivo software makes recapture much easier and faster than with manual coding (Zamawe, 2015). For example, the researcher was able to link a sentence from one participant to another sentence from another participant and retrieve it with little effort and time. However, it was challenging to manage a large volume of data, so the researcher decided to use manual coding and saved all the data in Microsoft Word. The researhcer thought that managing large amounts of data might have been difficult if she had used NVivo software, and it would have been more time-consuming as the researcher would need to be an expert in using NVivo.

119 3.16 Ethical Considerations

Ethical issues may appear in a study that do not fit the general ethical principles of autonomy, beneficence and non-maleficence (Beauchamp and Childress, 2001). When researchers conduct a research study that includes human participants, this may produce undesired outcomes (Sarantakos, 1998). Thus, the researcher sought in this study to foster an ethical approach at all stages to minimise any kind of harm to the study participants. Data for the study were collected after obtaining ethical approval from the Research Ethics Committee at The UOM (see Appendix 14) and the Research Ethics Committee at the Ministry of Health in Oman (see Appendix 15). Ethical approval was obtained concerning the following points.

3.16.1 Informed consent and voluntary participation It is essential that researchers ensure that all potential participants are able to provide their voluntary, informed consent to participate in the study (Barton et al., 1996). Informed consent was obtained for this study prior to the data collection process. Participation in a study should be optional and based on participants’ full understanding of their involvement in the research (Green and Thorogood, 2013). According to some researchers, a verbal agreement may constitute informed consent; however, written consent is considered the best form of informed consent (Gray, 2013) and is also required by an ethics review. In this study, participants who signed the informed consent form participated voluntarily. As all potential participants were strangers to the researcher, they did not feel any obligation to participate in the study. Healthcare professionals were also recruited to this study. There were no power asymmetries between them and the researcher because the researcher was not working in the healthcare institutions from which the healthcare professionals were recruited. No potential participants were placed under any pressure to participate in this study at any time. Postnatal women were identified for interview and observation through a leaflet (see Appendices 16 and 17), which was distributed by the facility gatekeepers; it was thus unlikely that the women felt obliged to participate in the study. The gatekeepers were recruiting midwives who did not provide care to potential participants at the respective study sites.

In order to recruit healthcare professionals for the interviews, the contact details of the researcher were included on the poster. Any healthcare professionals who wanted to volunteer to participate were able to contact the researcher; thus, no one forced them to

120 participate. In addition, access to family members was achieved via the women who participated in the study; therefore, they were unlikely to experience any coercion from the researcher to participate. For the clinical observations, the recruiting midwives accessed potential respondents (healthcare professionals) through a leaflet that was distributed to all healthcare professionals working in the maternity units; thus, they were not forced to participate in the study. The researcher aimed to address the issue of coercion by reaching potential participants through leaflets, poster advertisements and help from the gatekeepers and participating women in recruiting others. In this way, it was unlikely that study participants felt that they were obligated to participate in this study. The researcher also explained to the study participants that they would be able to withdraw from the study without giving a reason and they could withdraw their data if they wanted up to the point of the data analysis. However, participants could no longer withdraw their data when the researcher reached the stage of anonymising transcriptions or at the point of publication of the thesis. If potential participants showed an interest in taking part in the study, they were given a PIS. They were asked if they agreed to have their telephone contact details passed to the researcher. The researcher then obtained their telephone number from the gatekeepers.

The researcher contacted potential participants by telephone about one week after they had been given the PIS in order to provide them with time to think about whether they wanted to participate. During the contact call, the researcher explained the study and answered the respondents’ questions. The researcher reiterated that participation was voluntary and that a decision not to participate would not influence their healthcare. A time and place suitable for the participants to be interviewed were identified, which was either at the participants’ home or a meeting room in the health centre in accordance with the participant’s wishes. All the participants understood the PIS and, in general, the responses from the potential participants were positive. Before each interview and observation, the researcher asked those who chose to participate in the study to complete and sign the consent form. For women and their family members, the PIS and consent forms were in Arabic (see Appendices 18-23). The researcher also gave them an opportunity to withdraw from the study without the need to provide a reason.

3.16.2 Autonomy The interviews included discussing the personal views of women participants about EBF. Alty and Rodham (1998) indicate that a research study that concentrates on discussing

121 sensitive topics may affect the emotional state of the participants. Thus, during the interviews with the women, the researcher was vigilant in checking for signs of distress or discomfort. One of the women participants became uncomfortable during the interview. As a result, the researcher stopped the interview immediately and told the woman that she did not have to answer questions if they affected her negatively. In accordance with the study distress policy (see Appendix 24), the researcher gave the woman the chance to leave the study if she wanted or to delay the interview and resume on an alternative day, but that was not required. After a short rest, the woman asked the researcher to continue the interview and she stated that the questions helped her to express her feelings. The researcher gave all participants (women, their family members and healthcare professional) the chance to leave the study if they wanted. The participant stated that she felt comforted and thanked the researcher at the end of the interview. She also confirmed that she did not want a midwife to support her. None of the participants asked to withdraw or to remove their interview transcript from the study, although they understood that they were allowed to do so.

3.16.3 Confidentiality and data storage Participants’ confidentiality is a critical principle in research ethics (Maylor et al., 2016) and participants’ information should be handled safely and securely (Woulds, 2004). In this study, the principles of confidentiality and privacy were applied carefully. Participants’ identity was protected by using pseudonyms, all the collected data were anonymised (Woulds, 2004) and all personal details about the study participants were kept separately in a locked cabinet in the researcher’s office in Oman. Before storing the participants’ data, the researcher ensured that any identifying information was removed (Creswell, 1998). The researcher transcribed verbatim all audio-recorded data and coded them as soon as possible after conducting the interviews, after which the audio recording was deleted. All data for this study were saved safely in accordance with the Data Protection Policy of The University of Manchester (UOM, 2015). Once data were transcribed, the researcher stored the material securely and all electronic data were kept in the encrypted server at her workplace in Oman, access to which was password- protected. She also anonymised all transcripts that were sent to the supervisory team through email for their guidance. In addition, the researcher informed all the participants that any publications and quotations would attribute pseudonyms to them to ensure the maintenance of anonymity. When the researcher returned to the UK, those data were

122 stored securely on The UOM server, access to which was password-protected, and hard copies were given to the supervisory team. Once the thesis writing and publications are completed, the recordings will be destroyed. All transcripts will be stored for a maximum of five years, in accordance with The UOM regulations on research data storage. The data gathered in this study will be utilised for this research only.

3.16.4 Lone working As most risks are considered to be unknown during fieldwork, it is essential that home visits are subjected to proper risk assessments. Researchers may be liable to harm during field visits, which may include visiting areas that are unfamiliar to them (Tisdale, 2003). Therefore, to guarantee the researcher’s safety during the data collection process, the researcher followed The UOM lone worker policy (see Appendix 25). According to the lone working policy, when assessing the associated risks, it is essential to consider factors such as knowing the history of the person being visited, family circumstances, travelling to isolated or rural areas, communications availability, and personal safety and security. To decrease the hazards to the lowest possible level, a risk assessment was carried out and the information was shared with the researcher’s colleagues (community support group), including the location to which the researcher was going; the people the researcher was visiting; contact details; expected arrival time and duration of the visit; and the expected completion time of the visit.

In this study, most of the interviews were conducted in the participants’ homes (out of 69 interviews, 60 were conducted in the home). Before the researcher attended, suitable precautions were taken. The researcher asked her colleagues (community support group) about the area that she planned to visit to evaluate its safety. As the participants had selected the locations for the interviews, the researcher arranged with them that she would only conduct the interviews during the day and within regular working hours. The researcher was also travelling long distances to collect data in different provinces. Therefore, the researcher had her phone with her at all times and she assigned the manager of home visits at one of the healthcare institutions to be her safety contact individual. The researcher told the safety contact the location of each interview and the estimated start and finish times. For example, the researcher texted him ‘begin’ when she started the interview and ‘finish’ when she had finished. Moreover, the researcher informed him when she left the place of the interview. Dickson-Swift et al. (2008) have referred to the importance of novice researchers having access to a supervisory team in order to deal

123 with whatever emotional struggles they encounter while conducting research. Thus, during this study, the researcher informed the supervisory team at The UOM via Zoom- in how the research was proceeding, which was without serious events. For example, the researcher was worried about one woman who became distressed while she was interviewing her, so she informed her supervisors about the situation and the process for implementing the distress policy. The supervisory team reassured the researcher and provided support for her as a novice researcher.

3.17 Summary

This study investigated the perceptions surrounding breastfeeding among breastfeeding women and other participants in Oman from different perspectives and followed a constructivist grounded theory methodology. The aims and objectives of the study aided the way in which the use of constructivist grounded theory methods was determined for the data collection and analysis process. Constructivist grounded theory was an appropriate approach for this study because it enabled the researcher to build a theory from the participants’ views and the knowledge of the researcher, without any presumptions, through memo-writing and simultaneous data collection and analysis. This methodology allowed the researcher to construct the overall experience of breastfeeding women in Oman and to understand different perspectives on EBF in Oman.

The next chapter highlights the socio-demographic characteristics of the study sample and the findings of the study.

124

Chapter Four: Introduction to the Research Findings

125 Introduction to the Research Findings

4.1 Overview

This research study was conducted to gain an in-depth understanding of EBF that is informed by breastfeeding women living in Oman. It aimed to explore the barriers to and facilitators of EBF. It was also intended to elicit the perspectives of family members and healthcare professionals and to explore how they support women who are breastfeeding. The study utilised a qualitative design using a constructivist grounded theory principle to gain an understanding of the reality of breastfeeding from different perspectives. Information was generated regarding the perceptions, attitudes and beliefs of the women who participated and the role of family members and healthcare providers in supporting women who are breastfeeding. The results of this study will help in the understanding of Omani women’s experiences of EBF within the Omani context. The results will also help determine factors among Omani women that affect breastfeeding during the first four months after giving birth. This study sought to explore women’s experiences around this crucial stage.

This chapter presents a description of the sample that participated in the study and describes the socio-demographic characteristics of the study participants. The method for presenting the findings of the study is given at the end of the chapter.

4.2 Study Sample Characteristics

A total of twenty-six postnatal women participated in the study: eleven women took part in semi-structured interviews and fifteen in non-participant observations. Five family members of some of the same women participants also took part in semi-structured interviews. In addition, twenty-two healthcare professionals took part in the study: seven in semi-structured interviews and fifteen in non-participant observations. The process started by interviewing breastfeeding women, then their family members and, finally, healthcare professionals. Different postnatal women and healthcare professionals were later identified and recruited to the clinical observations in different maternity units at the selected healthcare institutions. This section presents the demographic information of each group of participants separately. Socio-demographic information about the postnatal women is illustrated first, followed by details regarding family members and then healthcare professionals.

126 4.2.1 Access to and recruitment of research participants Approval to conduct this study was obtained from The UOM Research Ethics Committee (UREC) and the Research and Ethical Review and Approve Committee (RERAC) at the Ministry of Health in Oman. As soon as ethical approval was obtained, the researcher met the lead doctor of the Regional Ethical Committee (REC) at NBG and obtained a facilitating letter to enable data collection at one referral hospital and two health centres across three wilayats. The researcher then discussed the research study with the director of the referral hospital, the head of the Nursing and Midwifery Department there, and the heads of the health centres in the NBG and gained permission to begin the data collection process. The administrators helped the researcher to gain access to the study sites. The need to allocate gatekeepers to help identify and recruit postnatal women and healthcare professionals was explained to the administrators. The director of the hospital identified three midwives who were not involved in the care of women, who might potentially be research assistants in this study. These recruiting midwives helped to identify and recruit participants to the study. A gatekeeper is an individual who stands between researchers and potential participants (Keesling, 2008). Gatekeepers can be secretaries, administrative assistants, office managers, family members or housekeepers (Keesling, 2008). The gatekeepers for this study were the administrators of healthcare institutions belonging to the MOH in NBG. The administrators facilitated the access of the researcher to the selected healthcare institutions. Other gatekeepers were three midwives who did not work at the study sites or provide nursing care to women at the selected healthcare institutions. The recruiting midwives identified postnatal women and healthcare professionals from the healthcare institutions selected. The women participants also acted as gatekeepers by helping to identify family members who would be willing to participate in the study.

A one-hour orientation workshop was conducted with the recruiting midwives to explain the recruitment process (see Appendix 26). In accordance with the three midwives’ request, the orientation workshop was conducted in the hospital auditorium. The study aims and objectives and the initial sampling plans were explained. The researcher also explained the necessity to recruit participants according to the inclusion criteria and discussed the ethical considerations and consent process with them. The orientation workshop also allowed clarification of any doubts and concerns and allowed questions about the recruitment process to be answered. Participant information sheets (PIS) and

127 consent to contact forms (English and Arabic versions) that were necessary for the recruitment process were given to the recruiting midwives during the workshop.

Access to and recruitment of postnatal women for interviews For the semi-structured interviews, the recruiting midwives approached postnatal women and assessed them for eligibility to take part in the study. They then invited eligible postnatal women to take part by providing them with a leaflet about the study. Women who were interested in participating in the study were provided with a PIS (see Appendix 27). In total, twenty-five postnatal women were considered to be eligible for the study and were invited to participate; all of them stated they were interested in participating. The recruiting midwives obtained contact details (English and Arabic versions) from the women and passed the information to the researcher (see Appendices 28 and 29). The researcher then contacted potential participants by telephoning them approximately one week after they had been given the PIS in order to give them time to think about whether they wanted to participate. Of the twenty-five postnatal women who were interested in participating in the study, fourteen declined to participate when the researcher contacted them. The reasons given by the women for not participating were as follows: six were undergraduate students and had study commitments; seven had to stay at their mother’s home after childbirth, which was located in a remote area beyond NBG (the study catchment area); and one changed her mind for personal reasons. Thus, those fourteen women did not participate in the interviews. In total, eleven postnatal women took part in the interviews.

During the initial contact, the researcher explained the research process, allowed the women to ask questions and agreed a time and place to conduct the interviews. The researcher obtained informed consent (see Appendix 30) on the day of the interview after explaining the PIS. Participant demographics, obstetric information and breastfeeding history for the postnatal mothers were obtained (see Appendix 31). All the women who were interviewed agreed to continue follow-up interviews for four months or until they stopped breastfeeding, whichever occurred first. The interviews were conducted on the seventh day, and at one, two, three, and four months postnatally. Before each interview, the researcher called the women to confirm if they were still interested in participating in

128 the study. Figure 4.1 illustrates the access and recruitment process involved in interviewing the postnatal women who participated in the study.

The recruiting midwives invited all eligible women (n=25) to the study and they provided a study leaflet

Women who were interested in participating in the study were given a Participant Information Sheet (PIS)

The researcher contacted the women by telephone to confirm

their willingness to participate after 2-3 days postnatal

(n=14) women declined to participate (n=11) women agreed to participate in the study for various reasons in the study

The researcher thanked them During the call, the research process was explained, questions were answered and a time and place to conduct the interview were agreed

Informed consent was obtained on the

day of interview after explaining the PIS

Figure 4.1: Flow diagram showing access to and recruitment of postnatal women for interviews

129 Flow Diagram showing access to and recruitment of postnatal women Access to and recruitment of family members for interviews After the interviews with the postnatal women were completed, the researcher asked the women to invite their mother, mother-in-law and husband to participate in the study. Twenty-two family members were identified by the women for participation in interviews. Of those twenty-two family members, six agreed to be interviewed. Reasons for not participating in the study were given as health issues experienced by the women’s mother or mother-in-law. None of the women’s husbands agreed to participate in this study for various reasons. For example, five husbands replied that breastfeeding was not their business and they were not interested in participating and six were working in remote areas outside NBG and thus were not able to participate in the study. Of the six family members who were interested in participating, one declined because she had planned to take a holiday in Salalah (a long distance from the study site). As a result, a total of five family members participated in the study.

The researcher asked the women participants to give a PIS to family members who were interested in participating (see Appendix 32). The women participants provided the contact details of their family members and gave verbal consent for the researcher to contact them. The researcher then contacted the women’s family members by telephone to discuss the study process and to answer any questions. A time and place to conduct the interviews were agreed. Informed consent (see Appendix 33) was taken on the day of the interview after the researcher explained the PIS and confirmed willingness to participate in the study. Figure 4.2 illustrates the access and recruitment process regarding interviewing family members.

130

Women participants approached (n=22) family members and they obtained permission for the researcher to discuss the study process

Family members (n=6) were interested and agreed to participate in the interview and their contact details Family were given to the researcher members (n=16) were not interested in

participating A Participant information sheet (PIS) was given to family members who were interested in participating in the study by the women participants

The researcher contacted the family members by telephone to confirm their willingness to participate, to explain the research process, to answer any questions and agreed on the time and place to conduct the interview

One family member called the researcher The researcher contacted the participants one day before the interview to inform her again one day before the interview to that she would not be participating and confirm their participation

she did not sign an informed consent form

Five family members agreed to participate. The researcher explained the PIS on the day of the interview and they signed an informed consent form

Figure 4 .2: Flow diagram showing access to and recruitment of family members for interviews

Flow Diagram showing access and recruitment of the family members 131 Access to and recruitment of healthcare professionals for interviews Healthcare professionals were recruited for interviews through poster advertisements that were displayed by the recruiting midwives at the selected healthcare institutions (see Appendix 34). If healthcare professionals were interested in participating in the study, they could contact the researcher by telephone (using an office number). Ten healthcare professionals agreed to participate and seven consented (four midwives, one nurse and two midwives holding managerial positions). Three midwives declined to participate because of sudden health issues. During the initial contact, the research process was explained and the healthcare professionals were given the opportunity to ask questions. A convenient time and place to provide the PIS (see Appendix 35) and a location for conducting an interview were agreed. One week after providing the PIS, the researcher called the interested healthcare professionals and confirmed a time and place to conduct the interviews, as previously arranged. Informed consent (see Appendix 36) was taken on the day of the interview after explaining the PIS. The duration of each interview ranged from forty to seventy minutes for all participants. Figure 4.3 illustrates the access and recruitment process for the healthcare professionals relating to the interviews.

132

Healthcare Professionals (HCPs) were identified by poster advertisement

HCPs (n=10) were interested in participating, they contacted the researcher by telephone. Questions were answered and the time and place to give the PIS was agreed

The researcher contacted HCPs by telephone to confirm their participation and to agree on a time and place to conduct the interview

Three HCPs declined due to a health Seven HCPs confirmed their issue participation

The researcher explained the PIS on the The researcher thanked them day of the interview, and the HCPs signed an informed consent form

Figure 4.3: Flow diagram showing access to and recruitment of healthcare professionals (HCP) for interviews

133 Access to and recruitment of postnatal women and healthcare professionals for clinical observations

Clinical observations were conducted when all the interviews with the women, their family members and healthcare professionals had finished. In total, twenty low-risk women were identified by the recruiting midwives. The recruiting midwives invited the women (during pregnancy) to take part in clinical observations and gave women who were interested a PIS (see Appendix 37). The recruiting midwives provided the researcher with the contact details of the women. During the initial contact, the research process was explained and the researcher answered any questions. The researcher also identified a time and place to obtain informed consent (see Appendix 38) and emphasised that the women could withdraw at any time, even after they had provided consent. The researcher clarified that the women could withdraw their data if they wanted up to the point of the data analysis. The researcher also explained to the women that they would be accepted onto the study only if they met the inclusion criteria after childbirth. The inclusion criteria were as follows: Omani women aged 18 years and above, postnatal women who gave birth to a single healthy baby, and women who breastfed their babies exclusively during hospitalisation. On the observation day, five of the twenty women declined to participate because they felt tired after childbirth. In total, fifteen postnatal women were involved in clinical observations.

The recruiting midwives also identified fifteen healthcare professionals via an advertising leaflet (see Appendix 39). The midwives were caring for the women who participated in the clinical observations. Fifteen healthcare professionals were purposely recruited because it was important to make sure that they were in the observation area when the women arrived, and this was matched with the number of women who agreed to participate in the observations. All the healthcare professionals identified were interested and agreed to participate in observations. Those fifteen healthcare professionals were in addition to those who were interviewed. The recruiting midwives gave a PIS (see Appendix 40) to the healthcare professionals and provided the researcher with their contact details. During the initial contact, the researcher explained the study process and answered their questions. The recruiting midwives had a list of the women who had agreed to participate and they verified, by asking the shift in charge of the labour room, that the women on the list were the same as the women who had agreed to take part. When the women arrived at the labour room, the recruiting midwives informed the researcher

134 by telephone so that she could conduct the clinical observations. The recruiting midwives also ensured that the healthcare professionals who participated in the clinical observations were distributed on different shift patterns (day and night) so that the healthcare professionals who participated in the observations were the ones who took care of the women participants in the clinical observation area. The healthcare professionals’ working schedule was arranged with the help of the maternity unit managers. Informed consent (see Appendix 41) was obtained prior to the day of the observations.

Clinical observations were conducted to observe how healthcare professionals supported the practice of breastfeeding at different and separate maternity units in the selected healthcare institutions (five clinical observations were conducted in the labour room, five in the postnatal ward and five in the postnatal clinics). Each clinical observation lasted two to three hours. For example, the researcher observed participants’ behaviour and activities in the labour room and noted the environment, particularly the layout of the maternity unit and the waiting area. The researcher wrote down the duration of each visit, especially the length of waiting time, and the level of privacy for breastfeeding in the waiting area using the observation template. The researcher then followed each woman as she entered the postnatal ward and postnatal clinic to observe her interaction with healthcare professionals and how the healthcare professionals communicated with and supported the women in the follow-up appointments. The researcher recorded any healthcare intervention and health education provided by the healthcare professionals. The researcher also had the opportunity to observe some of the women during their physical examinations at different maternity units. She watched the social interaction and listened to the healthcare professionals while they spoke with the women. Figure 4.4 illustrates the access and recruitment process for the participants in the clinical observations.

135 Recruiting midwives approached participants for the clinical observations

Low risk women (n=20) were Healthcare professionals approached during antenatal visit (last (n=15) were approached at visit) due to short stay of women in the different maternal units hospital postnatal

Any women / HCPs who were interested in participating were given a copy of the PIS

The recruiting midwives provided the researcher the contact detail of the interested participants

The researcher contacted women / HCPs by telephone to confirm their participation, explain the research process and to agree on a time and place to obtain informed consent

Women (n=20) agreed to Healthcare professionals (n=15) participate agreed to participate

Informed consent was obtained by the researcher before the day of the clinical observations after explaining the PIS

On the day of the observations, women (n=5) declined for various HCPs (n=15) participated in the reasons. Postnatal women (n=15) study, no one declined participated in the study

Figure 4.4: Flow diagram showing access to and recruitment of research participants for the clinical observations

136 4.2.2 Total participants in this study In total, eleven postnatal women participated in the semi-structured interviews for four months or until they stopped breastfeeding, whichever came first. Five family members participated in semi-structured interviews. Also, seven healthcare professional participated in semi-structured interviews. Additionally, fifteen postnatal clinical observations were performed with women and their healthcare provider. Table 4.1 illustrates the total participants in this study.

Table 4.1: Total numbers of participants in this study Participants Postnatal Family Healthcare Total / Data Women Members Professionals Interviews Collection (n=11) (n=5) (n=7)

Number of Semi- 57 5 7 69 Structured Interviews

Postnatal Family Healthcare Total Women Members Professionals Number of Observations (n=15) (n=0) (n=15) Non- Participants 15 for both Observations 15 - 15 women and HCP

4.2.3 Socio-demographic information of the postnatal women A total of twenty-six women participated in this study (eleven women participated in interviews and fifteen women participated in observations). Of those twenty-six women, twelve were primigravida and fourteen multigravida. The ages of the women ranged from nineteen to forty-one years (the median was thirty-one years old). Fifteen women were unemployed, and eleven were employed in either the government or private sector. All working women planned to return to work after maternity leave fifty days) and annual leave except for one woman, who took a holiday without pay for one month in addition to the maternal and annual leave. Fourteen women had completed secondary school and twelve were college graduates. Childbirth for all the women participants involved a natural (vaginal) birth, the gestational ages ranged from 35–38 weeks, and all the babies were healthy.

137 All the women initiated breastfeeding within one hour of childbirth and were exclusively breastfeeding their baby in the hospital. Although the women introduced water with red seeds (garden cress seeds) in the first weeks after childbirth, it was still considered exclusive breastfeeding. The women considered garden cress seeds as medication for abdominal gases. There was variation in the intended breastfeeding duration for the women in this study. Additional demographic information for the postnatal women is noted in Table 4.1 (semi-structured interviews). The researcher did not collect detailed information from the women who participated in the clinical observations because the purpose of the observations was to observe how healthcare professionals supported breastfeeding women in the selected healthcare institutions. Additional information about the women who participated in the clinical observations is noted in Table 4.2 (clinical observations).

138 Table 4.2: Socio-demographic information of the postnatal women (interviews)

Pseudonym Muluk Moon Rose Safi Age 27 25 30 29 Marital State Married Married Married Married Parity Multigravida Primigravida Multigravida Multigravida Mode of Delivery Normal Childbirth Normal childbirth Normal childbirth Normal childbirth Gestation Age at Birth 37 weeks + 4 days 38 weeks +5 days 36 weeks + 2 days 36 weeks + 4 days Educational Statues High school diploma High school diploma College degree High school diploma Working State Employed Employed Employed Not employed (teacher) (accountant) (medical orderly) (House wife) Government Private sector Government Smoking State No No No No Initiating Breastfeeding Within ½ hour Within ½ hour Within ½ hour Within ½ hour Exclusive Breastfeeding No (water with red seeds) No (water with red seeds) No (water with red seeds) No (water with red seeds) Antenatal Education about BF Leaflet from MW Leaflet from MW Leaflet form MW Leaflet from midwife HE from student 7 months 8 months during pregnancy 7 months during pregnancy 8 months during pregnancy during pregnancy Sex of the Baby Girl Boy Girl Boy Intended Feeding Method BF – 2 M 1 ½ year 2 years 2 years Then AF Duration of Stop BF few days before 4 Stop BF few days before 4 Stop Bf at 3 months Stop BF at 2 months BF at 4 months months months Reasons for BF cessation Return to work Sore nipples Sore nipples Return to work Maternal leave (ML) / Annual leave 3 months (50 days ML and 2 months 3 months (AL) 40 days AL) + 1 month Nil 50 days ML and 10 days AL 50 days ML and 40 days AL leave without salary Family Members who Participated in the Interview Grandmother 3 Nil Mother in law 1 Nil

139 Pseudonym Nada Sweet Star Noor Age 22 36 41 20 Marital State Married Married Married Married Parity Primigravida Multigravida Multigravida Primigravida Mode of Delivery Normal childbirth Normal childbirth Normal childbirth Normal Childbirth Gestation Age at Birth 37 weeks + 6 days 35 weeks + 4 days 37 weeks 38 weeks Educational Statues College degree High school diploma College degree High school diploma Working State Not employed Not employed Employed (director) Not employed (House wife) (House wife) Government (House wife)

Smoking State No No No No Initiating Breastfeeding Within ½ hour Within 1 hour Within ½ hour Within ½ hour Exclusive Breastfeeding No (water with red seeds) No (water with red seeds) No (water with red seeds) No (water with red seeds) Antenatal Education about BF Nil Leaflet from MW Nil Nil 8 months during pregnancy

Sex of the Baby Boy Girl Boy Boy Intended Feeding Method 1 year 6 months 2 years 6 months

Duration of Continued BF more than 4 Stop BF at 2 months Stop BF few days before 4 Stop BF at 3 months BF at 4 months months months Reasons for BF cessation Continued BF Household activities Surgical intervention for Insufficient milk production Sore nipples breast Maternal leave (ML) / Annual leave Nil Nil 3 months Nil (AL) 50 days ML and 40 days AL

Family Members who Participated in Mother in law 2 Nil Grandmother 2 Nil the Interview

140

Pseudonym Somi Anwar Nawal Age 32 19 38 Marital State Married Married Married Parity Multigravida Primigravida Multigravida Mode of Delivery Normal childbirth Normal childbirth Normal childbirth Gestation Age at Birth 36 weeks +5 days 39 weeks 36 weeks + 1 day Educational Statues College degree High school diploma High school diploma Working State Employed Not employed Not employed (teacher) (House wife) (House wife) Government Smoking State No No No Initiating Breastfeeding Within ½ hour Within ½ hour Within ½ hour Exclusive Breastfeeding No (water with red seeds) No (water with red seeds) No (water with red seeds) Antenatal Education about BF Leaflet from MW Pamphlet from MW Nil 8 months during pregnancy 9 months during pregnancy

Sex of the Baby Boy Girl Girl Intended Feeding Method 4 months 1 year 6 months

Duration of Stop BF few days before 4 months Continued BF more than 4 months Continued BF more than 4 months BF at 4 months Reasons for BF cessation Return to work Continued BF Continued BF Maternal leave (ML) / Annual leave 4 months (50 days ML and 40 days AL, 1 (AL) Nil Nil month because mother have extra days)

Family Members who Participated in the Interview Nil Grandmother 1 Nil

141 Table 4.3: Socio-demographic information of the postnatal women (clinical observations)

Pseudonym Aisha Maha Reem Safyia Seham Age 22 29 35 23 40 Marital State Married Married Married Married Married Parity Primigravida Primigravida Multigravida Primigravida Multigravida Mode of Delivery Normal Childbirth Normal childbirth Normal childbirth Normal childbirth Normal childbirth Gestation Age at Birth 37 weeks + 6 days 35 weeks +5 days 36 weeks + 5 days 36 weeks + 6 days 36 weeks Educational Statues High school High school diploma High school diploma College degree College degree diploma Working State Not employed Not employed Employed Not employed Employed (House wife) (House wife) Private sector (House wife) Government Smoking State No No No No No Initiating Breastfeeding Within ½ hour Within ½ hour Within ½ hour Within ½ hour Within ½ hour Antenatal Education Leaflet form MW

about BF Nil Nil Nil Nil 8 months during pregnancy Sex of the Baby Girl Girl Girl Boy Boy Intended Feeding Method 6 months 2 years 2 years 1 year 6 months Maternal leave (ML) / 3 months 50 days Maternal 50 days ML and 40 Annual leave (AL) Nil Nil leave Nil days AL

142 Pseudonym Asma Hifa Amina Hajer Khadija Age 28 39 37 20 38 Marital State Married Married Married Married Married Parity Primigravida Multigravida Multigravida Primigravida Multigravida Mode of Delivery Normal childbirth Normal childbirth Normal childbirth Normal childbirth Normal childbirth Gestation Age at 36weeks + 6 days 37weeks + 4 days 36weeks + 4 days 38 weeks 38 weeks + 1 day Birth Educational Statues College degree High school diploma College degree High school diploma College degree Working State Not employed Not employed Employed Not employed Not employed (House wife) (House wife) Government (House wife) (House wife) Smoking State No No No No No Initiating Within ½ hour Within ½ hour Within ½ hour Within ½ hour Within ½ hour Breastfeeding Antenatal Education Pamphlet from MW about BF Nil Nil Nil Nil 7 months during pregnancy Sex of the Baby Boy Girl Boy Boy Girl Intended Feeding 2 years 2 years 1 year 2 years 1 year Method Maternal leave (ML) 3 months (50 days ML Nil Nil Nil Nil / Annual leave (AL) and 40 days AL)

143 Pseudonym Rahma Fatiya Hanan Iman Noof Age 25 36 32 41 34 Marital State Married Married Married Married Married Parity Multigravida Primigravida Multigravida Primigravida Primigravida Mode of Delivery Normal Childbirth Normal childbirth Normal childbirth Normal childbirth Normal Childbirth Gestation Age at Birth 35 weeks + 4 days 37 weeks +5 days 38 weeks + 2 days 36 weeks 38 weeks Educational Statues High school diploma College degree College degree College degree High school diploma Working State Employed Not employed Employed Employed Not employed Private sector (House wife) Private sector Private sector (House wife) Smoking State No No No No No Initiating Breastfeeding Within ½ hour Within ½ hour Within ½ hour Within ½ hour Within ½ hour Antenatal Education Leaflet form MW about BF Nil Nil Nil Nil 8 months during pregnancy Sex of the Baby Girl Boy Girl Boy Girl Intended Feeding Method 6 months 2 years 1 year 2 years 2 years

Maternal leave (ML) / 2 months 3 months 50 days ML and 15 50 days ML and 40 Annual leave (AL) 50 days maternal leave Nil Nil days AL days AL

144

4.2.4 Socio-demographic information of the family members As mentioned above, none of the women’s husbands participated in this study (see section 4.2.1.2). In total, five family members took part in the study. The five family members were senior females (older women) who had long experience with breastfeeding. They were considered experts in breastfeeding because they had breastfed between eight and twelve children for more than one year. Of those older women, three were grandmothers (the woman’s mother) and two were mothers-in-law (the husband’s mother). Three of the older women were married and two were widows. The ages of the older women at the time of the data collection ranged from sixty to seventy-two years. All the older women lived in NBG in Oman.

4.2.5 Socio-demographic information of the healthcare professionals In total, seven healthcare professionals took part in semi-structured interviews and fifteen healthcare professionals participated in clinical observations. With regard to the seven healthcare professionals interviewed, five provided care to women postnatally at different maternity units in the selected healthcare institutions (four were midwives and one was a nurse). There was a marked difference between the midwives and nurses in the care they provided to women. The midwives carried out deliveries, which cannot be done by nurses. Four of the healthcare professionals held a diploma in nursing and midwifery certificate (midwives) and had received eighteen months of training at one of the local nursing and midwifery institutions, and one held a diploma in nursing certificate (nurses). Their experience ranged from six to eleven years. Of the five healthcare professionals, one had completed a breastfeeding counselling course because she had worked in another country (the UAE) before she started working at the study site. The health system in the UAE is similar to that in Oman with regard to breastfeeding and healthcare institutions in the UAE follow the WHO recommendations on breastfeeding and BFHI guidelines. All the healthcare professionals worked different shift patterns (day and night). Additional demographic information about the healthcare professionals is noted in Table 4.3.

145

Table 4. 4: Socio-demographic information of the healthcare professionals

Pseudonym Certificate Years of Place of Shift Midwifery Continue Breastfeeding Experience Work Pattern Training Education for Counselling Midwives Training Midwife 1 Diploma in Nursing and 8 Delivery Day & 18 months No No Diploma in Midwifery Room Night (Midwife) Midwife 2 Diploma in Nursing and 10 Delivery Day & 18 months No No Diploma in Midwifery Room Night (Midwife) Nurse 3 Diploma in Nursing 6 Post-natal Day & No No No (Registered General Ward Night Nurse) (Nurse) Midwife 4 Diploma in Nursing and 7 Post-natal Day & 18 months No Yes Diploma in Midwifery Ward Night (Midwife) Midwife 5 Diploma in Nursing and 11 Post-natal Day 18 months No No Diploma in Midwifery Clinic (Midwife)

146 Additionally, two maternity unit managers were also included in the interviews to explore their views on breastfeeding and the duties of midwives and nurses with regard to breastfeeding. They were midwives and held managerial positions in the maternity units of the selected healthcare institutions. One of the managers was in charge of the labour room and the other was the head of a maternity unit. Manager 1 had sixteen years’ experience and Manager 2 had twenty-two years’ experience. Both managers had completed eighteen months of midwifery training but had not undergone continuing education for midwives or breastfeeding counselling training. Manager 1 worked different shifts (day and night) and Manager 2 worked on the day shift only. Socio- demographic information for the maternity unit managers is shown in Table 4.4.

Table 4.5: Socio-demographic information of the maternity unit managers

Pseudonyms Manager 1 Manager 2

Certificate Diploma in Nursing Diploma in Nursing Diploma in Midwifery Diploma in Midwifery

Year of Experience 16 22

Place of Work In-charge of Labour Head of Maternity Units Room

Shift Pattern Day & Night Day

Midwifery Training 18 months 18 months

Continue Education for Midwives No No

Breastfeeding Counselling Training No No

Engagement in clinical experience Before 6 years Before 12 years

147 As referred to earlier, fifteen healthcare professionals participated in the clinical observations. Of those fifteen healthcare professionals, ten held a diploma in nursing and midwifery certificate (midwives) and had received eighteen months of training at one of the local nursing and midwifery institutions, and five held a diploma in nursing certificate (nurses). Their experience ranged from six to thirteen years. All the healthcare professionals worked different shift patterns (day and night). Additional socio- demographic information for the healthcare professionals (clinical observations) is noted in Table 4.5

148 Appendix 38: Socio-demographic Characteristics of the Healthcare Professionals Table 4.6: (SocioObservations-demographic information) of the healthcare professionals (observations)

Pseudonym Certificate Years of Place of Shift Midwifery Continue Breastfeeding Experience Work Pattern Training Education Counselling for Midwives Training Midwife 6 Diploma in Nursing 8 Delivery Day & 18 months No No and Diploma in Room Night Midwifery (Midwife) Nurse 7 Diploma in Nursing 9 Post-natal Day & No No No (Registered Ward Night General Nurse) (Nurse) Midwife 8 Diploma in Nursing 13 Delivery Day & 18 months No No and Diploma in Room Night Midwifery (Midwife) Midwife 9 Diploma in Nursing 11 Delivery Day & 18 months No No and Diploma in Room Night Midwifery (Midwife) Nurse 10 Diploma in Nursing 10 Post-natal Day & No No No (Registered Ward Night General Nurse) (Nurse) Midwife 11 Diploma in Nursing 12 Delivery Day & 18 months No No and Diploma in Room Night Midwifery (Midwife) Nurse 12 Diploma in Nursing 7 Post-natal Day & No No No (Registered General Ward Night Nurse) (Nurse)

Midwife 13 Diploma in Nursing 6 Maternity Day 18 months No No and Diploma in clinics Midwifery (Midwife) Midwife 14 Diploma in Nursing 8 Maternity Day 18 months No No and Diploma in clinics Midwifery (Midwife)

149

Pseudonym Certificate Years of Place of Shift Midwifery Continue Breastfeeding Experience Work Pattern Training Education Counselling for Midwives Training Nurse 15 Diploma in Nursing 11 Post-natal Day & No No No (Registered General Ward Night Nurse) (Nurse) Midwife 16 Diploma in Nursing 10 Maternity Day 18 months No No and Diploma in clinics Midwifery (Midwife) Midwife 17 Diploma in Nursing 9 Delivery Day & 18 months No No and Diploma in Room Night Midwifery (Midwife)

Midwife 18 Diploma in Nursing 11 Maternity Day 18 months No No and Diploma in clinics Midwifery (Midwife) Nurse 19 Diploma in Nursing 13 Post-natal Day & No No No (Registered General Ward Night Nurse) (Nurse)

Midwife 20 Diploma in Nursing 7 Maternity Day 18 months No No and Diploma in clinics Midwifery (Midwife)

150 4.3 Presenting the Findings

This study explores the perspectives of breastfeeding women, their family members and healthcare professionals with regard to breastfeeding. In-depth knowledge of the barriers to and facilitators of breastfeeding was identified by conducting interviews and observations. The data from the interviews and observations underwent constant comparative analysis and different categories and sub-categories were developed (see Table 4.6). Three main categories emerged from the consistent analysis of the data: Breastfeeding Expectations; Breastfeeding Support; and Breastfeeding Journey. These categories were identified through the understanding gained of data collected from different perspectives. The women’s experiences of breastfeeding started with their expectations that breastfeeding was their responsibility and a natural process, until they discovered the reality. The women’s experiences of breastfeeding are presented in chapters five, six, and seven. The constant comparative analysis of the findings indicated that there was a connection between the three categories in this study, which enabled the core category, ‘Navigating the Reality of Breastfeeding’, to emerge. The analysis also showed that there was linkage between the core category and the theory, which helped the emergence of the grounded theory, named ‘Resilience: The Power to Breastfeed’. The core category and the grounded theory are discussed in chapter eight.

151 Table 4.7: Categories and sub-categories of the research findings Categories Sub-categories

‘I knew that I would breastfeed.’ Breastfeeding

Expectations ‘It is a natural process.’

Expecting support.

Lacking preparedness for breastfeeding.

Family members’ presence. Breastfeeding Support Lack of healthcare professionals’ support.

Early breastfeeding experiences. Breastfeeding Journey Women’s ability to breastfeed.

The findings of this research study are presented using excerpts from the participants’ interview transcripts to illustrate their experiences and views. Each excerpt is identified by a pseudonym to maintain the participants’ anonymity. Participants’ quotations are included in the findings chapters to provide a rich background and context and to appreciate the participants’ experiences. In cases in which an ellipsis is included in the quotation (‘...’), this is to manage space constraints, which means that a portion of the participant’s transcript was considered to be content that would not modify the context of the quotation if deleted.

For the interview excerpts, the pseudonyms are assigned in parentheses after each quotation, followed by the woman’s status and whether she was a mother for the first time or already had children (PG: primigravida or MG: multigravida women, respectively). Then the duration of breastfeeding is stated (number of months) and the number of the interview conducted with each woman; for example: (Muluk, MG: 4 months, Interview

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1). For the interviews with family members and healthcare professionals, a descriptor of the participant is written in parentheses after each quotation, followed by the number of the participant; for example: (Grandmother 2) and (Midwife 1).

The clinical observations and field notes are placed in a box to differentiate them from the quotations from the interviews. The observation number is written inside the box, followed by the location of the clinical observation, such as: (Observation 1, PNW) (PNW is the postnatal ward). The full terms for the abbreviations are mentioned in the list of abbreviations at the start of the thesis. Multiple clinical observations are presented as: (Observation field notes). In the clinical observation and field note boxes, the researcher has also presented the findings using the first-person pronoun “I”.

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Chapter Five: Breastfeeding Expectations

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Breastfeeding Expectations

5.1 Overview

This chapter discusses women’s understanding and perceptions of breastfeeding and how they constructed their breastfeeding expectations before childbirth. The chapter describes the expectations of the women and their family members who took part in this study with regard to breastfeeding and illustrates how those expectations influenced the women’s preparedness for breastfeeding before starting to do so.

The first category, Breastfeeding Expectations, is composed of four sub-categories: ‘I knew that I would breastfeed’; ‘It is a natural process’; Expecting support; and Lacking preparedness for breastfeeding. The four sub-categories are discussed in detail below.

5.2 ‘I Knew That I Would Breastfeed’

‘I knew that I would breastfeed’ was a term used by most of the women to describe their expectations of breastfeeding before childbirth. The data revealed that the women’s expectations of breastfeeding their baby were constructed based on three aspects: social norms within the Omani context, Islamic guidelines on breastfeeding, and the health benefits of breastfeeding. Each of the aspects is explained separately below. This sub- category also illustrates how the expectations influenced the women’s perceptions of breastfeeding. As a result, the majority of the women in this study had been looking forward to breastfeeding and expected to breastfeed in the future.

5.2.1 Social norms within the Omani context The interviews revealed that all the women perceived breastfeeding as a social norm. The importance of breastfeeding as a method for infant feeding began to be constructed when the women were small girls. The women reported that they were exposed to breastfeeding within their close family and the surrounding community during their early life because they lived in homes structured around an extended family. As a result, they assumed that breastfeeding was one of the social norms that should be practised by women. They connected breastfeeding with women and made statements such as, ‘all women were breastfeeding their children’ and the ‘women in my family were breastfeeding’. As a result, they expected to breastfeed in future. For example,

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“When I was a small girl, we were living in my grandfather’s house…I saw the women in my family were breastfeeding their baby...I understood breastfeeding was food for the baby…it is like traditional practice or social practice, so I knew that I would breastfeed one day.” (Nada, PG: continued BF more than 4 months, 1st Interview)

Nada’s mother-in-law also emphasised the importance of exposing young women to other breastfeeding women when they were young. According to her, observing breastfeeding women helps young women who do not have experience of breastfeeding to learn about it and will thus stimulate women’s desire to breastfeed in future:

“The young women should see and learn from breastfeeding women because women know that they would breastfeed their baby one day…If they see breastfeeding women, they will have the desire to breastfeed in the future.” (Mother-in-law 2)

The excerpts above demonstrate that exposure to breastfeeding women within the close family and broader community had shaped women’s perceptions and influenced their breastfeeding expectations before initiating breastfeeding; thus, they expected to breastfeed.

As the breastfeeding concept was constructed by interactions with close family members and the wider community in which the women lived, this led the women to believe that breastfeeding was a normal practice that was learned from the older generation. This is explained by Moon, a primigravida woman, in the next excerpt:

“I knew that I would also breastfeed in the future because all women in Oman are breastfeeding…it is a normal practice for women in Oman, my mother told me.” (Moon, PG: 3 months, 1st Interview)

Although many of the women believed that breastfeeding was a normal practice that was based on what they learned from the older generation, other women learned from the older generation that breastfeeding was considered to be the mother’s responsibility. Before childbirth, many of the women felt responsible for breastfeeding because they would be a mother; thus, they expected that they would breastfeed their baby. Rose and her mother-in-law emphasise this idea in the following excerpts:

“Before birth, I learned from my mother that breastfeeding is my responsibility as a mother...I knew that I have to breastfeed my baby after birth.” (Rose, MG: 2 months, 1st Interview)

“I breastfed all my children because breastfeeding was my responsibility… Breastfeeding was women’s duty as a mother, and they have to be responsible.” (Mother-in-law 1)

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Therefore, it was evident from the interviews that women linked breastfeeding with motherhood because their mothers always connected breastfeeding with a mother’s responsibility.

Not only was there an assumption that women would breastfeed their baby because that was part of being a mother, it was also clear from the women’s statements that there was a connection between breastfeeding and being a good mother. For example, Muluk expressed how she was thankful to Allah because she could breastfeed her baby. This feeling developed because she considered herself a good mother when she was breastfeeding, as narrated in the next excerpt:

“I am thankful to Allah that I have this power to continue breastfeeding until today...I must breastfeed my baby so that I would be a good mother.” (Muluk, MG: 4 months, 2nd Interview)

The excerpts above indicate that the women’s primary concern was breastfeeding, as they believed that it falls under their responsibility as mothers, just as they had learned from their own mothers. This was because most of the women looked to elder family members as role models in whose steps they needed to follow with regard to breastfeeding. In the next excerpt, Star recalls that she expected to breastfeed her baby and she regarded her own mother as a role model because her mother had breastfed her and all her brothers and sisters. This led Star to believe that in order to be a good mother, like her own mother, she had to breastfeed her baby, as explained below:

“My mother told me that she breastfed me when I was a baby. She also breastfed all of my brothers and sisters. We were nine brothers and sisters, so I want to do like my mother. She is my role model…I wanted to breastfeed and to be a good mother like her…I knew that I would breastfeed because I want to be like my mother.” (Star, MG: 4 months, 1st Interview)

Star’s mother added:

“The good mothers are breastfeeding their baby and I was teaching my daughter that.” (Grandmother 2)

It seems from the previous excerpts that the women’s knowledge that their mother breastfed them when they were infants increased their desire to breastfeed in the future. Women expected to breastfeed in order to be like their mother and had not even considered other options.

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Upon probing, many of the women added that they trusted their mother’s knowledge because their mother had experience of breastfeeding; thus, they followed their mother’s guidance on breastfeeding. For example, Muluk, an educated woman and working mother, expresses her trust in her mother’s knowledge in the next excerpt:

“I trust my mother’s knowledge and experience on breastfeeding because she breastfed all my brothers and sisters. Thus, I am following her instructions on breastfeeding.” (Muluk, MG: 4 months, 1st Interview)

This section has shown that the women who participated in the research had constructed their breastfeeding expectations within their close environment. Exposure to breastfeeding women within the close family and broader community had influenced the women’s breastfeeding expectations and led them to believe that breastfeeding was a normal practice and a mother’s responsibility. They connected breastfeeding with motherhood and being a good mother. In addition, some of the women expected to breastfeed as they looked to their mother as a role model; thus, they wanted to follow the same notion by following in their mother’s footsteps. The breastfeeding women trusted older family members’ knowledge because they believed in the credibility of their knowledge and experience.

5.2.2 Islamic guidelines on breastfeeding In Islam, the Holy Quran emphasises the importance of breastfeeding and specifies an appropriate length of time (two years) if the woman is able to breastfeed. Islam gives flexibility and the option to mothers regarding the decision and duration of breastfeeding. In Islam, it is preferred that women breastfeed their baby for two years, but there is no obligation upon women to breastfeed if they cannot do so. All the women who participated in the study are Muslims and they expected to breastfeed their baby before childbirth based on the recommendations in the Holy Quran. For example,

“Breastfeeding is written in the Holy Quran, and Allah recommended breastfeeding for two years for the women who can breastfeed; thus, as a Muslim woman I knew before my birth that I would breastfeed my baby.” (Moon, PG: 3 months, 1st Interview)

During the interviews, the women were asked about the length of time they expected to breastfeed. There were variations in the women’s stated intended length of breastfeeding. Despite breastfeeding being optional, three of the women stated they intended to breastfeed for two years, based on the Holy Quran’s recommendation. For example, the

158 data indicated that Star interpreted the length of breastfeeding as her responsibility, as illustrated in the excerpt below:

“Breastfeeding is written in the Holy Quran from more than 1400 years. It is mentioned in the Holy Quran that the women who are able to breastfeed should breastfeed their baby for two years. I believed what is written in the Holy Quran is good for the people and because breastfeeding for two years is written in the Holy Quran, thus the women should be responsible for breastfeeding for two years. Thus, I planned to breastfeed my son for two years.” (Star, MG: 4 months, 1st Interview)

Some of the women added that before childbirth they had expected to breastfeed their baby, as they did not want to deviate from the Islamic guidelines on breastfeeding. This is explained by Muluk and her mother in the following two excerpts:

“Before my birth I expected to breastfeed my baby because Allah recommended breastfeeding in the Holy Quran, and I want to follow what is written in the Holy Quran, I do not want to deviate from the Holy Quran recommendation.” (Muluk, MG: 4 months, 2nd Interview)

“Breastfeeding is important, thus Allah mentioned breastfeeding in the Holy Quran, women knew that they would breastfeed their baby because Allah recommended breastfeeding.” (Grandmother 3)

Other women added that Allah would reward breastfeeding women for their effort when they breastfed their baby; therefore, before childbirth, they expected to breastfeed their baby so that they would not be prevented from receiving Allah’s reward. This expectation was stated by Nawal as well as Nada’s mother-in-law:

“I knew that Allah will reward breastfeeding women because they spend their time, health and effort to breastfeed their baby…I expected to breastfeed my baby before birth because I wanted this reward from Allah.” (Nawal, MG: continued BF more than 4 months, 1st Interview)

“In the Holy Quran, Allah said that he will reward women for caring for their baby, so women breastfed to obtain Allah’s reward.” (Mother-in-law 2)

This section has revealed that the women also constructed their breastfeeding expectations based on Allah’s recommendation of breastfeeding in the Holy Quran, despite breastfeeding being optional. The data indicated that women perceived the length of breastfeeding, identified in the Holy Quran as two years, as their duty. The data showed that knowing the Islamic recommendation on breastfeeding had influenced women’s breastfeeding expectations and led the women to believe that if they did not breastfeed, they would be deviating from the Islamic guidelines on breastfeeding. Women expected to breastfeed their baby to obtain Allah’s reward. 159

5.2.3 Benefits of breastfeeding The women had redefined their responsibility in the form of the benefits breastfeeding would bring. Women expected to breastfeed their baby because they believed that they were responsible for their baby through the benefits of breastfeeding. According to the majority of the women who took part, during pregnancy, they had learned from older family members about the importance of breastfeeding, such as the benefits of breastfeeding for babies’ health. As a result, the women expected to breastfeed their baby so that their child would gain the health benefits of breastfeeding. For example, Muluk stated that she expected to breastfeed her baby because of the importance of breastfeeding for her baby’s health, as learned from her mother:

“My mother taught me about breastfeeding…She taught me about the benefits of breastfeeding for the babies, especially the yellow milk [colostrum]…I knew that I would breastfeed my baby because I want to give my milk to my baby because it is good for my baby’s health...breastfeeding protects the babies from infections, it increases the immunity of the babies, it helps in growth and development of the babies physically and psychologically. It also increases attachment between women and their babies.” (Muluk, MG: 4 months, 1st Interview)

Star added, after further probing, that she is responsible for giving good food to her baby, as described in the next excerpt:

“I am a mother, and it is my responsibility to give my baby the best food and breastfeeding is good for my baby.” (Star, MG: 4 months, 1st Interview)

The majority of the women expected to breastfeed so that their baby could gain the health benefits of breastfeeding, although other women added that they would breastfeed to gain the benefits of breastfeeding for themselves as well. Many of the women reported the importance of breastfeeding for their own health, as it would help them recover after childbirth. For example, Nada, a primigravida woman, listed some of the health benefits of breastfeeding for breastfeeding women that she had learned from her mother:

“I learned from my mother the importance of breastfeeding for the breastfeeding women. She told me that breastfeeding helps to reduce bleeding after birth; it also helps the baby house [uterus] to return to its normal position…I breastfeed because breastfeeding is important for me.” (Nada, PG: continued BF more than 4 months, 1st Interview)

Other women explained the importance of breastfeeding for their physical appearance; as a result, before childbirth, they expected to breastfeed their baby. For example, Anwar, a 19-year-old primigravida woman, described her expectation of breastfeeding based on its importance in reducing her weight: 160

“I read in the leaflet the midwife gave me when I visited the health centre during my pregnancy the importance of breastfeeding for breastfeeding women and I read that breastfeeding reduces the weight of breastfeeding women. Thus, I expected to breastfeed my baby because I want to reduce my weight.” (Anwar, PG: continued BF more than 4 months, 1st Interview)

Star (41 years old) added that before childbirth she expected to breastfeed her baby to gain the benefits of breastfeeding as a birth spacing method:

“My mother told me about the importance of breastfeeding for breastfeeding women when I got pregnant for the first time and she is still reminding me of the importance. She told me that breastfeeding helps to delay pregnancy, so I expected and wanted to breastfeed because I did not want to get pregnant fast.” (Star, MG: 4 months, 1st Interview)

This section has revealed that women constructed their breastfeeding expectations before childbirth based on knowing the benefits of breastfeeding for their baby, which led the women to feel responsible for giving good food to their baby. Knowing the health benefits of breastfeeding had influenced the women’s breastfeeding expectations and led them to believe that if they breastfed, they would gain benefits from breastfeeding. They had not wanted to deny their baby and themselves the benefits of breastfeeding.

This sub-category (‘I knew that I would breastfeed’) revealed that the women constructed their breastfeeding expectations through social norms that were acquired within the Omani context, Islamic guidelines regarding breastfeeding, and the benefits of breastfeeding. Through the women’s interaction within the Omani context, they believed that breastfeeding was a normal practice and a mother’s responsibility. Therefore, the women connected breastfeeding with motherhood and being a good mother. In addition, the women looked to their own mother as a role model because their mother had breastfed all her babies. The women also perceived that their responsibility to breastfeed their baby came from Islamic guidelines that stated that mothers breastfeed their baby for two years, despite this being optional. This responsibility was also perceived in the form of benefits for their baby. As a result, the majority of the women who participated in the research knew that they would breastfeed because they aimed to gain some benefits from breastfeeding for their baby. They believed that breastfeeding would prevent diseases, increase immunity, and improve the growth and development of their baby. Other women looked to some of the gains that were related to themselves, such as a speedy recovery after childbirth, improved physical appearance and breastfeeding acting as a birth spacing method.

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5.3 ‘It is a Natural Process’

‘It is a natural process’ was another term used by the majority of the women to describe their breastfeeding expectations before childbirth. The interviews showed that women’s breastfeeding expectations were based on their perception of breastfeeding as a natural process for them and their baby, learned from the older generation. The majority of the women described this as a natural process and as an innate practice, something that will happen naturally and an easy mothering practice. As a result, many of the women expected to breastfeed their baby.

Before childbirth, many of the women believed that breastfeeding was a natural process for them and their baby and expected breastfeeding to happen immediately after birth. During the interviews, they used phrases such as ‘normal process’ to describe the concept of the natural process of breastfeeding; therefore, they expected to breastfeed. For example, Moon mentioned that before childbirth she understood from her mother that breastfeeding was a natural process; as a result, she expected her baby to breastfeed immediately, as narrated in the following excerpt:

“Before my birth, I expected to breastfeed because I knew from my mother that breastfeeding is a natural process, she told me that the baby would breastfeed after birth...I thought that my baby will immediately breastfeed because I knew that breastfeeding would be like an innate practice because it is a normal process.” (Moon, PG: 3 months, 1st Interview)

Rose’s mother-in-law emphasises the same notion in the next excerpt and this was observed during the clinical observations in the labour room:

“Baby will breastfeed immediately after birth...breastfeeding is a normal process...It is an innate practice.” (Mother-in-law 1)

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Developing the concept of natural

In the labour room, I observed that the grandmother was helping her daughter during breastfeeding initiation. She also explained the importance of breastfeeding, especially colostrum for the baby. She emphasised the need for her daughter to give colostrum to the baby because of its importance and she was making sure that her daughter gave colostrum to her baby. She mentioned lots of health benefits of breastfeeding for the baby. For example, she said that “breastfeeding protects your baby from infections” and “breastfeeding will make your baby healthy”. While the grandmother was explaining the importance of breastfeeding to the woman, she mentioned that “breastfeeding is a natural process” and “breastfeeding is natural food for your baby”. She also said that “breastfeeding is natural because it is from Allah”. (Observation 1, Labour room)

It was not only the primigravida women who perceived breastfeeding as a natural process; multigravida women, such as Star, also perceived breastfeeding in that way. Star states below that she had breastfed her previous daughters for over a year:

“Breastfeeding is a natural process, I breastfed all my three daughters for more than one year…I knew that I would breastfeed my new baby because breastfeeding is a natural process.” (Star, MG: 4 months, 2nd Interview)

Other women believed that breastfeeding was a natural behaviour and would happen spontaneously, something they understood from their mothers; as a result, they expected to breastfeed their baby. For example, Noor illustrates her expectation to breastfeed in the following excerpt:

“Breastfeeding is a natural process, it is a natural behaviour which will happen, and it will happen spontaneously after birth...I learned from my mother.” (Noor, PG: 3 months, 1st Interview)

It was evident from the interviews that before childbirth some of the women expected that breastfeeding would be an easy mothering practice for them; as a result, they expected to breastfeed their baby. For example:

“I expected breastfeeding would be an easy practice for mothers before birth.” (Nada, PG: continued BF more than 4 months, 1st Interview)

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This section has demonstrated that the majority of the women perceived breastfeeding as an innate practice, something that will happen naturally and an easy mothering practice that would happen spontaneously. Therefore, the majority of the women expected to breastfeed.

5.3.1 ‘Natural food for the baby’ The women and older family members who took part in the study used the word ‘natural’ to describe breast milk. All the women with older family members, without exception, appreciated breast milk and stated that their confidence in breastfeeding was due to understanding breast milk as a natural food for a baby. Before childbirth, some of the women believed that breast milk is a natural food for the baby because it comes from their body and, because of this, they expected to breastfeed:

“Breast milk is good and healthy for my baby; it is natural milk…milk is coming out from my body...It is a natural food for the baby.” (Star, MG: 4 months, 2nd Interview)

Star’s mother also emphasised the same concept and added that breast milk is a gift from Allah because it comes from a woman’s body:

“Breast milk is natural and a gift from Allah for mothers and their baby. It comes from women’s bodies, so it is a natural food for the baby.” (Grandmother 2)

Other women understood that breast milk is a natural food for a baby because they believed that Allah created the breast for feeding, as described by Muluk in the following excerpt:

“Breast milk is gold and a gift from Allah, who created breasts for feeding, so I expected to breastfeed my baby before my birth because Allah created breasts for feeding…breast milk is a natural food for the baby.” (Muluk, MG: 4 months, 2nd Interview)

The data revealed that before childbirth, the women expected to breastfeed because they conceived of breastfeeding as a biological function of the breast.

This sub-category revealed that the women expected to breastfeed based on their perception that breastfeeding was a natural process. They understood breastfeeding as an innate practice, something that will happen, a natural behaviour and an easy mothering practice; as a result, they expected that breastfeeding would happen immediately and spontaneously after childbirth. The women also believed that breast milk is a natural food

164 for the baby because it comes from the body and that Allah created breasts for feeding. Therefore, before childbirth, the women expected to breastfeed.

5.4 Expecting Support

This sub-category illustrates the women’s expectations regarding support. Before childbirth, primigravida women had expected to receive support from their family during the breastfeeding period; however, after childbirth, they discovered that their family’s support was only for a period of up to six weeks, as mentioned in the next excerpt:

“I expected that my family would support me when I breastfed after my birth, of course my mother supported me but only for forty days [six weeks] after birth, not more…I did not know that it is for six weeks only.” (Moon, PG: 3 months, 2nd Interview)

Primigravida women also expected support from healthcare professionals during the breastfeeding period but then realised that the healthcare professionals were not going to support them, as mentioned by Moon:

“I thought the midwives would support me after my birth but when I asked, they were not supportive.” (Moon, PG: 3 months, 2nd Interview)

While the primigravida women did not realise that support would be limited to the first six weeks after giving birth, multigravida women were aware that any support would be for that period only. The multigravida women justified the reason for giving six weeks of support by stating that their family wanted them to be independent after six weeks and to depend on themselves for breastfeeding. For example,

“I knew that support will be for forty days only because my mother wanted me to breastfeed without her support and to depend on myself.” (Sweet, MG: 2 months, 2nd Interview)

Upon probing, a question was posed to multigravida women about why they had not made any preparations during pregnancy. Sweet replied that she thought that she was ready to breastfeed because of her previous experience:

“I breastfed before, and I thought that I would breastfeed my baby without problems.” (Sweet, MG: 2 months, 2nd Interview)

Other multigravida women who were working in a full-time job expected their family to support them beyond a six-week period because they would then return to work and leave

165 their baby with their mother. For example, Muluk stated that it was important to have her family’s support during the working day:

“I expected my mother to support me when I return to my work...when I delivered my baby in the last pregnancy, my mother supported me when I returned to work, I kept my son with her, so I knew that she would support me this time also.” (Muluk, MG: 4 months, 2nd Interview)

Multigravida women did not expect to receive support from healthcare professionals after their previous breastfeeding experience:

“I did not expect support from the midwife, they did not support me before and I know they will not support me now.” (Muluk, MG: 4 months, 2nd Interview)

The three previous sub-categories (‘I knew that I would breastfeed’, ‘It is a natural process’ and Expecting support) revealed that the women’s expectations had influenced their preparedness for breastfeeding. Before childbirth, the women felt ready for breastfeeding; thus, they did not actively prepare themselves for breastfeeding before childbirth. Their lack of preparedness for breastfeeding is discussed in the next sub- category.

5.5 Lacking Preparedness for Breastfeeding

In the previous three sub-categories (‘I knew that I would breastfeed’, ‘It is a natural process’ and Expecting support), the data revealed that the majority of the women expected to breastfeed based on their perception that breastfeeding was a natural process and that it was their responsibility as a mother. The women expected to breastfeed because they understood that breastfeeding would occur immediately and spontaneously. The primigravida women expected family members and healthcare professionals to support them during the breastfeeding period. As a result, before childbirth, the women believed in their ability to breastfeed and they felt prepared for doing so. The multigravida women knew, however, that family support would not extend more than six weeks after childbirth and that healthcare professionals would not support them during the breastfeeding period.

The following was, however, noticed during the interviews when the women were asked about their need for breastfeeding preparedness before childbirth. The primigravida women had overlooked the need to learn breastfeeding skills during pregnancy because they perceived breastfeeding as a natural process that would happen immediately after

166 childbirth; as a result, they felt that they would be able to breastfeed and would be ready for breastfeeding. For example,

“Before birth, I did not think to prepare myself for breastfeeding, what I understood was that breastfeeding was like a natural process, so I thought that my baby would breastfeed directly after birth, I thought that I will be able to breastfeed.” (Anwar, PG: continued BF more than 4 months, 1st Interview)

Other primigravida women overlooked the need to learn breastfeeding skills because they knew they would be supported by family members, as described in the following excerpt:

“My mother was always telling me that she will help and support me after my birth, so I expected that I will be able to breastfeed because my mother will support and help me, so I felt that I did not need to prepare for breastfeeding.” (Moon, PG: 3 months, 2nd Interview)

Many of the primigravida women felt during pregnancy that they would be able to breastfeed and were prepared for breastfeeding because they had the impression they had obtained sufficient information about it from older family members. They did not ask healthcare professionals about breastfeeding during the antenatal period as they felt ready for breastfeeding. For example, at the end of the first month after childbirth, Nada felt that she had good experience of breastfeeding and she did not feel a lack of preparation:

“My mother taught me about breastfeeding and the importance of breastfeeding during my pregnancy...she told me a lot about benefits of breastfeeding for the baby and for me also...I felt that I am ready to breastfeed and I will be able to do that [breastfeed], because I had sufficient information about breastfeeding benefits...I did not ask the midwife about breastfeeding because I felt ready for breastfeeding from the information that I got from my mother…I did not need to be ready, I am doing well with breastfeeding.” (Nada, PG: continued BF more than 4 months, 2nd Interview)

Similarly, multigravida women believed that they would be able to breastfeed their baby because they would be able to rely on their previous experience as a mode of breastfeeding preparation. According to one participant,

“I know how to breastfeed because I breastfed before, I had breastfeeding experience, so no need to prepare for breastfeeding.” (Muluk, MG: 4 months, 1st Interview)

The above excerpts show that before childbirth, the majority of the women believed in their ability to breastfeed and they felt prepared for it due to their perception that breastfeeding was a natural process, they would be supported when needed, had sufficient information about breastfeeding or had previous experience.

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The healthcare professionals were asked about breastfeeding preparation before childbirth. They stated that they were already overloaded with work and there were no breastfeeding classes to teach women how to breastfeed:

“It is difficult to teach women with this huge number of women in the maternity units…We are too busy and overcrowded with lots of work in one shift…there is not classes to teach women about breastfeeding…also I knew that their mothers would support their daughter during breastfeeding, it is our culture.” (Midwife 2)

A question was asked of older family members about breastfeeding preparation before childbirth. They stated that they did prepare women for breastfeeding before childbirth. The older family members believed that they were preparing women for breastfeeding by providing information about breastfeeding and its health benefits; thus, they felt that their daughters were ready for breastfeeding, as in the account by Muluk’s mother in the next excerpt:

“Yes, I am preparing my daughters for breastfeeding...before birth I told my daughters about breastfeeding and the importance of breastfeeding for the baby...All these would help the women to learn breastfeeding and they will be ready for breastfeeding.” (Grandmother 3)

The older family members considered exposure to breastfeeding women before childbirth as one of the methods for learning about and preparing to do it. As a result, before childbirth, the older family members felt that their daughters were ready for breastfeeding:

“We were preparing women for breastfeeding by exposing them to other breastfeeding women.” (Mother-in-law 2)

Upon probing, older family members were asked during the interviews about whether they taught the practical components of breastfeeding before childbirth. The older family members did not prepare their daughters for how to breastfeed before childbirth, as they believed that their daughters would understand breastfeeding after childbirth during the real experience of breastfeeding and having a real baby, as referred to in the following statement:

“I taught my daughters how to breastfeed after birth. Women will know and understand how to breastfeed after birth because they will understand how to breastfeed their baby…they need to know how to breastfeed with real experience and a real baby.” (Grandmother 1)

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Noor reiterated that her mother taught her how to breastfeed after childbirth, as shown in the next excerpt:

“No, my mother did not teach me about how to breastfeed during pregnancy. She taught me after the birth of my baby in the labour room.” (Noor, PG: 2 months, 2nd Interview)

Upon probing, the women were asked about the proper timing for learning breastfeeding and how to breastfeed. The majority of the women emphasised the importance of learning how to breastfeed during pregnancy and after childbirth, as illustrated in the following:

“I need to learn about breastfeeding, especially how to breastfeed before birth and to emphasise how to breastfeed after birth.” (Rose, MG: 2 months, 2nd Interview)

From the excerpts above, it can be seen that the older family members believed they had prepared women for breastfeeding before childbirth. They exposed women to other women who breastfed their baby and provided information about breastfeeding in order for the women to learn about it. They taught the women the practical component of breastfeeding after childbirth, as they believed that the women would understand how to breastfeed with real breastfeeding experience and when presented with a real baby.

It was noted that before childbirth all the primigravida women believed in their ability to breastfeed; thus, they felt ready for breastfeeding. However, after childbirth, and once they started breastfeeding, they recognised that they were not fully prepared. They commented on the lack of preparation before childbirth in how to breastfeed, which affected their ability to breastfeed after the birth, as described in the following excerpt:

“I thought breastfeeding is a natural process and it will happen, but after my birth, I recognised that breastfeeding is not what I thought...I discovered that I was in need of learning how to breastfeed before my birth.” (Noor, PG: 3 months, 1st Interview)

The primigravida women discovered the importance of preparedness for how to breastfeed after childbirth, whereas multigravida women believed that they had been in need of learning about breastfeeding challenges and how to manage them before childbirth, especially during the first pregnancy. For example, Rose believed that for “each baby, there is a new story and a new experience” of breastfeeding. She emphasised the importance of learning about breastfeeding challenges and how to manage them during the first pregnancy:

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“I have previous experience of breastfeeding, but it is not the same…Each baby has his way of breastfeeding. I feel that for each baby, there is a new story and a new experience…In the last breastfeeding experience with my daughter, I had breast engorgement, but this time I have sore nipples…I feel I needed to know breastfeeding difficulties and how to solve breastfeeding problems during the first pregnancy.” (Rose, MG: 2 months, 2nd Interview)

The data revealed that insufficient preparedness for breastfeeding was due to a lack of knowledge of two main aspects of breastfeeding: breastfeeding skills and breastfeeding challenges and their management. Not learning these two aspects of breastfeeding had affected the breastfeeding experiences of the women and is explored in detail in the third category: Breastfeeding Journey (see chapter seven). The majority of the women lacked preparedness for breastfeeding because midwives did not provide antenatal education during pregnancy, as described below:

“During my pregnancy, midwives did not teach me about breastfeeding or how to breastfeed when I was visiting the antenatal clinic. I thought they will teach me on breastfeeding and how to breastfeed…The midwives were only examining my abdomen, check my vital signs, took blood for investigation and documenting in the computer.” (Nada, PG: continued BF more than 4 months, 2nd Interview)

During the interviews, the healthcare professionals stated that breastfeeding was not part of their duties and that it is the grandmothers’ duty to teach their daughter. Thus, the healthcare professionals did not teach women how to breastfeed during pregnancy. The lack of preparedness for breastfeeding by healthcare professionals was witnessed during the clinical observations in different maternity units in the selected healthcare institutions.

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Practical sessions on breastfeeding

The observations took place on different days of the week, at different times during the clinic working hours, and included many healthcare professionals at the selected healthcare institutions. While conducting observations in the maternity units, I did not observe any healthcare professionals providing practical sessions for the women on breastfeeding techniques and breastfeeding positioning during the postnatal period. During the follow-up appointments in the postnatal clinics, I did not observe any theoretical or practical sessions on breastfeeding techniques and positioning for the breastfeeding women. The healthcare professionals were conducting other nursing activities, such as collecting blood, measuring the height and weight of the women and their baby, checking vital signs, and documentation. I observed that the healthcare professionals only asked the women if they were still breastfeeding or not for the purpose of documentation in the child health register. They did not ask the women about their experience of breastfeeding or if they had difficulties with breastfeeding. (Observation field notes)

5.6 Summary

It appeared from the interviews that breastfeeding was not a choice for the women in this study; instead, it was an expected social practice that was transferred from one generation to another. Before childbirth, the women expected to breastfeed their baby because they believed that breastfeeding was a mother’s responsibility, which is what they learned from the older generation. They also believed that breastfeeding was a natural process that would happen immediately and spontaneously after childbirth. Primigravida women expected family members and healthcare professionals to support them during the breastfeeding period. Multigravida women knew that they would not be supported by family members for more than six weeks after childbirth and that healthcare professionals would not support them at all. Multigravida women thought that they were ready to breastfeed because they would be able to rely on their previous experience. As a result, the multigravida women had believed in their ability to breastfeed and felt ready for breastfeeding. However, once they started breastfeeding, they discovered that they lacked preparedness for breastfeeding. During the antenatal period, the healthcare professionals 171 did not prepare women for breastfeeding. The impact of the lack of preparedness for breastfeeding is discussed in chapter seven (Breastfeeding Journey). The support the women received from their family members and healthcare professionals is discussed in the next chapter.

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Chapter Six: Breastfeeding Support

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Breastfeeding Support

6.1 Overview

This chapter presents the perspectives of breastfeeding women, their family members and healthcare professionals with regard to breastfeeding support. It describes the support that women received from family members and healthcare professionals after childbirth. The chapter also discusses some of the factors that affect breastfeeding support within the healthcare institutions and their impact on breastfeeding.

This category, Breastfeeding Support, is composed of two sub-categories: family members’ presence and lack of healthcare professionals’ support. The two sub-categories are discussed in more detail below.

6.2 Family Members’ Presence

All the women stayed with their mother up to six weeks after childbirth to regain energy and to learn how to breastfeed and care for their baby as part of the social practices of breastfeeding within the Omani context. The presence of older family members up to six weeks after childbirth is a social norm within the Omani community, as breastfeeding is learned from the previous generation. This practice is referred to in the following excerpt:

“After birth, women should stay with their mothers to regain their power and their health…I am teaching my daughters about breastfeeding and how to take care of their new baby. My daughters are staying with me for forty days [six weeks]. This breastfeeding practice is not a new thing. This is our culture and traditional practice and I have to support my daughter, this is my role.” (Grandmother 3)

The data indicated that the older family members believed that their presence immediately after childbirth was important to help their daughters to learn how to breastfeed and to support and reassure them, as described by Anwar’s mother:

“After birth, it is important for me to be with my daughters to teach how to breastfeed their baby, this is my role…Also, it is important for me to be with my daughters to support them and reassure them when they are breastfeeding.” (Grandmother 1)

The importance of family members’ presence was also emphasised by many of the women in this study. The women highlighted that their mother (grandmother) provided a helping hand for them when breastfeeding their baby and when they were learning how to breastfeed after childbirth. The women reported that their mother did everything for

174 them during the first six weeks. They appreciated the presence of their mother immediately after childbirth and during the first six weeks postnatal, as described by Moon, a primigravida woman:

“It was important for me that my mother stays with me after my birth…She was helping and encouraging me to start breastfeeding in the hospital. After birth, I have to stay with my mother for forty days. She was teaching me how to breastfeed my baby…I breastfed my baby because of my mother’s support, she did everything for me and my baby… I appreciate my mother because she was with me.” (Moon, PG: 3 months, 1st Interview)

Whereas primigravida women emphasised the importance of their mother’s presence in doing everything for them and in learning how to breastfeed, multigravida women asserted the value of their mother’s presence in recalling how to breastfeed, as reported by Muluk below:

“I had breastfeeding experience, but I forgot how to breastfeed because I breastfed five years ago...I need my mother to remember how to breastfeed.” (Muluk, MG: 4 months, 1st Interview)

Many of the women believed in the importance of their mother’s presence while they were breastfeeding their baby because their mother showed care and love for them and their baby, as shown in Safi’s account:

“My mother was with me all the time after birth. She was kind, loving me and my baby…She was helping me a lot with everything, not only breastfeeding, I love her.” (Safi, MG: 4 months, 1st Interview)

The presence of family members was important to encourage the women to breastfeed their baby. Many of the women reported that members of their family, such as grandmothers, mothers-in-law and husbands, made encouraging remarks; for example, ‘well done’, ‘good, keep on breastfeeding’ and ‘you are doing well’. For instance, in the next excerpt, Muluk states how she appreciated her family’s kind words when she was breastfeeding:

“When I was breastfeeding my baby at night, my husband was sitting with me until I finished breastfeeding. He was smiling and encouraging me to breastfeed my small baby. I felt that my husband’s words encouraged me to breastfeed. He was telling me that I am doing a good job with breastfeeding. He was telling me that I am a great mother. Also, my mother and my mother-in-law were telling me some good words, like you ‘are doing well’ and ‘well done’. These words encouraged me very much to breastfeed my baby.” (Muluk, MG: 4 months, 3rd Interview)

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Other women also indicated the importance of family members’ presence in sharing the happy event of the birth of their baby. For example, Star stated:

“It was important that my family stay with me after birth, not only my mother but also my sisters, my husband and all of my family. I felt pleased and calm to see my family and my mother around me to share my happiness on my baby’s birth.” (Star, MG: 4 months, 2nd Interview)

Upon probing with the women about their husband’s support, many commented that their husband had work commitments and returned home at the weekend. Thus, there was limited support from the women’s husbands:

“My husband is working in Muscat and he is returning back to his home at the weekend. He is encouraging me to breastfeed but not too much support like my mother.” (Moon, PG: 3 months, 4th Interview)

Many of the women believed in the importance of their mother’s presence during breastfeeding in order to share their mother’s (grandmother’s) experience of breastfeeding. This method of sharing helped the breastfeeding women to learn from their mother’s experience, as recounted by Star and her mother in the following statements:

“I am staying with my mother for forty days [six weeks] after my birth, and this is good because I am learning from my mother’s experience.” (Star, MG: 4 months, 2nd Interview)

“When I am teaching my daughters how to breastfeed their baby after their birth, I used my own breastfeeding experiences…I am sharing what I knew about breastfeeding with all my daughters, so that they could learn from my experience.” (Grandmother 2)

Upon probing, the older family members were asked about what experience they shared with their daughters about breastfeeding. The data demonstrated that older family members shared their successful experiences of breastfeeding because they wanted to encourage their daughters to breastfeed their baby, as described in the following excerpt:

“I am telling them how I succeeded during breastfeeding to encourage my daughters to breastfeed their baby.” (Mother-in-law 2)

Anwar’s mother added that they told their daughters about the success stories of breastfeeding but not the difficulties because they did not want their daughters to feel scared by the idea of breastfeeding challenges and then stop breastfeeding:

“I am sharing with my daughters my successful experience during breastfeeding…I am not telling them about the difficulties because I did not want to scare them...I am afraid that they will stop breastfeeding.” (Grandmother 1)

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Similarly, many of the healthcare professionals also believed that the presence of older family members with their daughters postnatally was essential to supporting and teaching them about breastfeeding. One of the midwives emphasised the importance of older family members’ presence in helping their daughters to initiate breastfeeding:

“It is important for the older family members to be with their daughters after childbirth in order to support their daughters while breastfeeding, especially initiating breastfeeding and teaching their daughters about breastfeeding.” (Midwife 1)

Other healthcare professionals reiterated the importance of the presence of older family members for their daughters. One midwife indicated that the presence of family members after childbirth was one of the social norms within the Omani community, in order to help breastfeeding women to breastfeed their baby:

“The presence of the older family members with the breastfeeding women is important to help the women to breastfeed their baby...this is one of the social norms for breastfeeding practice in Oman.” (Midwife 2)

The importance of the presence and support of the baby’s grandmother was seen during the clinical observation in the postnatal ward, as shown in the notes below.

Grandmother’s presence and her support

During the clinical observation in the postnatal ward, I observed that the grandmother was present most of the time with her daughter to help her in breastfeeding. I observed that the grandmother was teaching her daughter how to start breastfeeding. She was teaching her daughter breastfeeding positions and techniques. I also observed that the grandmother was supporting and encouraging her daughter to breastfeed the baby. In contrast, I observed that the midwives did not support the women while breastfeeding; instead they asked the grandmother. They did not help the women to initiate breastfeeding, and they did not teach them how to breastfeed. The midwives were doing their routine work, such as checking vital signs, performing random blood sugar tests for the baby, conducting physical examinations of the baby and for the women and documenting the results. (Observation 9, PNW)

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Although all the participants believed in the importance of family members’ assistance after childbirth, the presence of the family and their support with breastfeeding were limited to up to six weeks after childbirth. Many of the women reported that their mother’s support did not extend for more than six weeks after the birth and they reported that this period was not sufficient for them. For example:

“I stayed with my mother for forty days [six weeks] only,...this is not enough, I need more support from my mother…I need my mother’s support, not only during the forty days but after that as well [after six weeks].” (Moon, PG: 3 months, 3rd Interview)

Similarly, the majority of the healthcare professionals who participated emphasised the importance of ongoing support for the breastfeeding women, as shown in the next excerpt:

“Women need more support for breastfeeding, six weeks is not enough.” (Midwife 5)

In contrast, the majority of older family members felt that six weeks of support was enough and that after that time women had to depend on themselves with breastfeeding, as illustrated below:

“I supported my daughters for six weeks and this was enough, they have to depend on themselves for breastfeeding. They have to be responsible for their children and house.” (Grandmother 1)

This sub-category, Family members’ presence, showed the importance of the support of older family members for the breastfeeding women after childbirth. All the participants believed in the importance of family members’ presence with breastfeeding women postnatally, including the healthcare professionals. The women believed that the presence of their mother was needed so that they could do everything for them, to teach how to breastfeed, or to recall how to breastfeed, to show care and love, to share in the happy event of the birth of the baby, and to share their previous breastfeeding experience. When probing with the women about their husband’s support, it was evident that their partner’s support was not significant. The data also indicated that the healthcare professionals believed in the importance of family members’ presence (especially grandmothers) in supporting and teaching women about breastfeeding. However, the presence of grandmothers and their support was limited to up to the first six weeks after childbirth and did not extend beyond that period. Many of the women, including the healthcare professionals, believed that family support for up to six weeks was not enough. In contrast, the older family members believed that support for up to six weeks was enough

178 for the women because, according to them, the women then needed to depend on themselves for breastfeeding and other household activities. It seems that the majority of the women were still not ready to breastfeed on their own after six weeks postnatal. The impact of support in this transition period, for six weeks and then after six weeks postnatal, is discussed in chapter seven (section 7.3).

6.3 Lack of Healthcare Professionals’ Support

The majority of the women in this study reported that healthcare professionals did not support them during breastfeeding. The women were of the opinion that the healthcare professionals ignored the need for breastfeeding support, in both the hospital and the health centre. The women also maintained that healthcare professionals lacked empathy when dealing with them. According to Moon,

“The midwives were like a robot…They were in a hurry to finish their work…Thanks for Allah that my mother was with me after my birth because the midwives were not kind to me and they ignored me…They were not supportive during breastfeeding, they were not supporting breastfeeding…They were hindering breastfeeding because of their behaviour.” (Moon, PG: 3 months, 1st Interview)

Many of the women reported that midwives did not show supportive behaviour; as a result, they avoided asking the midwives questions immediately after childbirth:

“I did not receive breastfeeding support from the midwives. Sometimes, I avoid asking questions to them because they were not supportive and they did not show supportive behaviour.” (Star, MG: 4 months, 3rd Interview)

Although the majority of the women stated that they did not receive support from healthcare professionals, others reported that they did not obtain breastfeeding support after childbirth from the healthcare professionals even when they asked for help. For example, Rose expressed her anger with one midwife when she asked for help on how to breastfeed after the birth as follows:

“I was furious with the midwife because she did not help me when I asked her to help me how to breastfeed after my birth.” (Rose, MG: 2 months, 2nd Interview)

Other women also discussed the negative attitude of healthcare professionals, especially midwives, when they asked for help with breastfeeding. For example, Nada, a primigravida woman, talked about a harsh encounter with a midwife when she requested help with how to position her baby towards her breast immediately after giving birth.

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Later, Nada felt calm because her mother reassured her that she would teach her how to breastfeed. As a result, she avoided asking the midwives questions during her follow-up appointments in the postnatal clinics:

“The midwife was only ordering me to breastfeed my baby. She did not even give me my baby. She told me to breastfeed, and I told her to teach me. I did not know what to do, and she said to me: your mother will teach you and she went out. I was outraged, but my mother reassured me. She taught me how to breastfeed my baby after birth…I avoid asking them questions because of their behaviour…I do not like to ask them questions during my visit to the postnatal clinics.” (Nada, PG: continued BF more than 4 months, 2nd Interview)

During the interviews with the women, many of them reported the negative attitude of healthcare professionals. Thus, it was important to observe the attitude of healthcare professionals when they were dealing with women during breastfeeding in different maternity units.

Healthcare professionals’ attitude towards breastfeeding women

During the clinical observations in different maternity units, I did not observe healthcare professionals supporting breastfeeding women during breastfeeding. Also, I did not notice any negative attitude by the healthcare professionals in the maternity units. The healthcare professionals were caring respectfully for the postnatal women. They were smiling when they provided nursing care to women during the postnatal period. Although the healthcare professionals were not supporting women while breastfeeding, they still had good communication with the women and their family members. For example, the midwife was talking kindly when she did sutures for a woman after childbirth. Also, the midwives were talking nicely when they requested the grandmothers to support the women to initiate breastfeeding. The healthcare professionals were busy conducting their routine care of mothers and infants. For example, they were checking vital signs, examining women and their babies, assessing the women and their babies, calling the doctors in case of emergency and documenting in different records and computers. (Observation field notes)

The above observation was supported by Nada’s mother-in-law, who appreciated the way that the healthcare professionals dealt with her:

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“The midwives, nurses, all behaved well with me, and they dealt nicely with me, they were smiling, and the midwives were asking me to help my daughters in a good way in the hospital.” (Mother-in-law 2)

Other women added that the midwives directed them to their mothers when they asked for breastfeeding support in the labour room; as a result, they avoided the healthcare professionals after childbirth, as illustrated in the next excerpt:

“I did not know how to breastfeed my baby in the labour room, and I asked support from the midwife, the midwife told me that your mother will teach you…thus, I did not ask them later because I knew that they would direct me to my mother.” (Nada, PG: continued BF more than 4 months, 1st Interview)

Upon probing during the interview with Manager 1, I asked why the midwives directed breastfeeding women to their mother during the initiation of breastfeeding. She explained that the role of the grandmothers was to help their daughters to initiate breastfeeding as a social norm in Oman. She also justified it by explaining that midwives had a lot of work to do for the mother and their baby. As a result, the midwives asked the grandmothers to help their daughters to initiate breastfeeding:

“It is well known in the Omani culture that the grandmothers are helping their daughters to initiate breastfeeding...the midwives are busy and they have to do lots of nursing interventions for the women and their baby.” (Manager 1)

From the excerpts above, it can be seen that the majority of the women believed that midwives lacked empathy, their behaviour was not supportive, they did not give support even when they were asked, they showed negative behaviour and redirected the breastfeeding women to older family members (grandmothers); thus, the women avoided the midwives during later follow-up appointments. Some of the women’s narratives were supported during the clinical observations and the managers’ interviews, such as the lack of support for breastfeeding and breastfeeding women being redirected to their mothers. During the observations, I did not witness any support for breastfeeding in the healthcare institutions. However, I did not observe negative behaviour from the healthcare professionals during the clinical observations either, although that might have been due to my presence in the observational sites.

Similarly, Nada’s mother-in-law emphasised that the midwives did not support her daughters during breastfeeding in the hospital but instead asked her to support her daughters while initiating breastfeeding:

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“Midwives were always asking me to teach my daughters how to breastfeed and they did not support my daughter during breastfeeding, I did.” (Mother-in-law 2)

Many of the women and their family members regarded the healthcare professionals as non-supportive with regard to breastfeeding, and the healthcare professionals also acknowledged that they did not support women during breastfeeding. This was witnessed during the clinical observations in many of the maternity units.

Breastfeeding support by the midwives

The observations were performed at different maternity units with different healthcare professionals. During the observations, I observed in the labour room that the midwives did not advise the women to initiate breastfeeding. I also observed that the midwives were very busy and they were performing their routine work, such as they were more concerned with disinfecting the equipment and caring for the women after giving birth, such as suturing. Also, they were caring for babies such as measuring their length and weight and completing documentation. The midwives did not explain breastfeeding, its advantages and the disadvantages of mixed feeding to the women. I also observed that the breastfeeding women were asking the midwives for breastfeeding support, and the midwives were replying that they will come back but, unfortunately, they did not return to help the women during breastfeeding. (Observation field notes)

Some of the midwives believed that breastfeeding was not part of their duties. They believed that breastfeeding was the grandmother’s duty, based on the social norm within the Omani context; as a result, they did not support women during breastfeeding in the maternal units because they knew that older family members would help their daughters. As one midwife explained,

“The role of the grandmothers is to help their daughters for breastfeeding…it is not my duty...breastfeeding support by the older family is a social norm in Oman; thus, the grandmothers have to support their daughters for breastfeeding, not me…I did no support because I know that the grandmothers will support their daughters.” (Midwife 1)

Another of the midwives indicated that she did not teach women the practical side of breastfeeding because she did not consider it her role and she expected the grandmothers to teach their daughters after childbirth. Midwife 2 clearly stated that she relied on the

182 grandmothers to educate their daughters about breastfeeding, as shown below:

“I knew that the women’s mothers [the grandmothers] would teach their daughters about breastfeeding, and they would support them. This practice is a social norm in Oman, so I was not teaching the women how to breastfeed after birth…I was relying on the grandmothers to teach their daughters how to breastfeed their baby.” (Midwife 2)

Although some of the midwives did not support women during breastfeeding due to their belief that this was not their duty, one midwife reported that she did not support women during breastfeeding if the women had previous experience of breastfeeding. For example, Midwife 5 believed that multigravida women knew how to breastfeed their baby due to their previous experience; as a result, she did not support them during breastfeeding:

“To me, I did not provide breastfeeding support for the multigravida women because they knew how to breastfeed their baby...they had previous experience.” (Midwife 5)

Other midwives added that they were busy and there was a shortage of staff in the healthcare institutions; as a result, they did not support the women during breastfeeding. However, they also knew that the shortage of staff had affected the quality of care provided to women within healthcare institutions. This is reflected in the following excerpts:

“I know that I have to support the women in the hospital, but most of the time I am too busy, and I have to take care of three to four women in one shift, and I need to take care of their babies as well. I have to document all the care of both the women and their baby. I do not have time to listen or talk to the women while breastfeeding, but I know I have to do that [breastfeeding support], I know that I am not supporting breastfeeding women but we do not have lots of midwives.” (Midwife 2)

“We do not have enough midwives and nurses; thus, we do not support the women while breastfeeding...I think this shortage affected the quality of care to the women.” (Midwife 1)

Similarly, the maternity unit manager explained the impact of the shortage of midwives on the availability of breastfeeding support. She also justified the lack of professionals’ support for the women during the breastfeeding period as follows:

“Generally, the midwives and nurses are very busy because they are caring for a huge number of women in one shift; thus, they did not support women while breastfeeding…We do not have enough midwives in this health institution, so the midwives cannot support breastfeeding women…If the MOH provided enough

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midwives, they can support the women during breastfeeding… I think lack of staff, especially midwives, has affected breastfeeding support but what we can do? It is not in our hands.” (Manager 2)

Other midwives stated that the MOH breastfeeding policy (see Appendix 42) was not clear because no one had explained the policy when they first started the job. They added that there were no breastfeeding experts to which they could refer; as a result, they did not support the women during breastfeeding. This is illustrated in the following excerpt:

“When I joined the work, no one explained about the breastfeeding policy. I did not get any orientation about breastfeeding policy. It was not clear for me because I did not receive any training, and thus, I did not support the women because I did not want to do something wrong…There were no breastfeeding experts for breastfeeding to refer to them.” (Midwife 2)

Upon probing, Manager 1 acknowledged that the breastfeeding policy was not clear and that she had not received training regarding the policy; as a result, she did not explain the breastfeeding policy to new midwives:

“Breastfeeding policy is not clear because no one explained this policy to me, and I did not get any training about the breastfeeding policy...I could not explain this policy to the new midwives because it was not clear to me; thus, I was asking them to read this policy.” (Manager 1)

From the above interviews, it was necessary to observe breastfeeding policy to see if the role of healthcare professionals with regard to breastfeeding is identified in the breastfeeding policy from the MOH.

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Breastfeeding policy

The breastfeeding policy in Oman was adopted from the WHO recommendation of breastfeeding. This policy emphasised the importance of exclusive breastfeeding for six months after birth and to continue breastfeeding for two years. This policy encourages healthcare professionals to support women during breastfeeding. However, I did not observe the role of healthcare professionals in supporting women in this policy. Besides, I observed that the breastfeeding policy was posted in a place where the women cannot read it. For example, in the postnatal clinic, the breastfeeding policy was placed in the left corner of the room, so it was difficult for the women to read because it was placed above the woman’s chair. Also, there was no breastfeeding policy in the waiting area of the antenatal and postnatal clinics. (Observation field notes)

In addition, other midwives did not support women during the breastfeeding period due to their lack of breastfeeding counselling training and they expressed a need to receive training in how to counsel women on breastfeeding. According to Midwife 2,

“I did not support women during breastfeeding because I did not know how to provide breastfeeding counselling in a professional way...Midwives need to get training on how to support the women, we cannot support the women haphazardly …I think all midwives need to get breastfeeding counsellor training to know how to support the women in a professional way, especially for the primigravida women.” (Midwife 2)

Furthermore, the short amount of time the women stayed at the hospital after childbirth affected the midwives’ ability to teach the women about breastfeeding immediately after childbirth, as shown below:

“Women stay for one day in the hospital and they were sleeping after birth, so it is difficult to teach them in that time because they were tired from the labour and they got the chance to sleep when their baby was sleeping or when the babies were with their mothers [the grandmothers].” (Midwife 2)

“Usually, women stay at the hospital for a short time after birth, so the midwives do not have time to teach the women about breastfeeding...They stayed for twenty- four hours or less; thus, it was difficult to teach women.” (Manager 1)

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Women’s short stay in the hospital was witnessed in the next observations in the labour rooms and postnatal ward.

Short stay in hospital

During the clinical observations, I observed in the labour room and postnatal ward that the women stay in the maternity units for a short time: twenty-four hours for a normal birth. The women spent most of the time in the labour room for the birth process. During the women’s stay in the hospital, the healthcare professionals contacted the women if they or their baby had a health problem or if the midwives wanted to provide nursing care to the women or their baby. I also observed that after childbirth the women were sleeping most of the time. (Observation field notes)

During interviews with healthcare professionals, they reported that breastfeeding support is not mentioned in their job description. As a result, they were not willing to support breastfeeding because they did not want extra work. For example, Midwife 4 stated:

“To be honest, why do I have to support the women for breastfeeding? Breastfeeding support was not mentioned in my job description…there is nothing about breastfeeding support in my job description.” (Midwife 4)

During my presence in the maternity units, I noticed that there were many nurses working on the postnatal ward; thus, during the interviews with the maternity unit managers, I asked them about the roles of the midwives and nurses in the maternity units and the hierarchy of duties for the two sets of professionals. Moreover, the healthcare professionals had reported that nothing was mentioned in their job description about breastfeeding, so I wanted to make sure of this point with the maternity unit managers. After the interviews with the managers, the outcome was that the midwives and nurses followed the same job description; however, the difference was that the midwives could perform deliveries for the women. One of the managers showed me the job descriptions of the nurses and midwives, which mentioned nothing about breastfeeding support. According to Manager 1, the job title of the midwives within the MOH was nurse- midwife, and they followed the same job description as the general nurses. She added that

186 nothing was mentioned in the job description for the general nurses about breastfeeding support:

“In the Ministry of Health, the midwives do not have their own job description because their title is a nurse-midwife and they have a job description of a general nurse…breastfeeding support is not mentioned in the job description of the general nurses.” (Manager 1)

In addition, Midwife 5 stated that she did not teach women about breastfeeding techniques because of the unavailability of a breastfeeding room within the healthcare institutions, which was also witnessed during the clinical observations in different healthcare institutions. This is commented upon in the following excerpt:

“As you see, there is no breastfeeding room or at least a private room to teach women about breastfeeding, you know it is difficult to teach the women about breastfeeding in this open area [office in the waiting area], males are coming and going, so it is difficult to support the breastfeeding women here [waiting area].” (Midwife 5)

Breastfeeding classes or rooms and breastfeeding counselling

During the observations, I did not notice any breastfeeding classes or rooms for the women in the health centres selected. Also, there were no breastfeeding counselling rooms at the different healthcare institutions. The desk of the midwife who received the postnatal women was located in the waiting area. Then the midwife directs the women to wait beside the assessment room for a physical examination. (Observation field notes)

A contrasting view was presented by Nurse 3. Nurse 3 had graduated from the nearest neighbouring country and then started work in one of the healthcare institutions in Oman. She claimed that she supported breastfeeding women according to their needs by first assessing those needs. She suggested that support should include the interaction between the midwife and the woman to enable assistance to be given based on the woman’s requirements. However, she stated that she was only able to support breastfeeding women if she had time to do so due to the overcrowded nature of the work:

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“When the woman arrives here [working area], I ask her if she has special needs with regard to breastfeeding...interaction between the midwives and women is important to assess women’s needs...Then, I provide support or advice to the women according to the women’s needs, but I cannot support women continuously because I am busy and overcrowded with lots of work here [working area].” (Nurse 3)

From the quotations above, it seems that since there was no job description about breastfeeding support, the healthcare professionals supported women according to the time available. Nurse 3 added that she provided verbal feedback for primigravida women on breastfeeding techniques before they were discharged from the hospital:

“It is important to tell the women how they did while breastfeeding. Sometimes, I provide verbal feedback for each woman on breastfeeding techniques, especially the primigravida women, because they would lose their confidence to breastfeed if they did not know how to breastfeed...I give feedback before discharge from the hospital.” (Nurse 3)

Nurse 3 also considered the importance of providing practical advice as part of breastfeeding support, such as information about breastfeeding, techniques and challenges. According to Nurse 3, she told the women what they should look for during breastfeeding and why; however, her support was dependent on the time available and the degree of workload at work:

“On the women’s breast, I show why I want the baby to breastfeed in a certain way. I explain what they should look for because they might have problems like damaged nipples. Also, I tell the women about breastfeeding difficulties and how to solve these difficulties when I have time for that.” (Nurse 3)

A few of the midwives reported that they supported women during their follow-up appointments after childbirth by talking with them about their breastfeeding experience. They stated, however, that their support for breastfeeding women was dependent on their workload and the time available in the healthcare institutions. As one midwife explained,

“I know that I need to support the women, but it is difficult to support the women here in this clinic [working place]. I need to provide care for this huge number of women after birth, but I support breastfeeding women when I have time to do that …I talk with them about their breastfeeding experience when I have time for that.” (Midwife 5)

Midwife 4 stated that she provided two follow-up appointments for breastfeeding women during the first six weeks after childbirth: one in the second week and again in the sixth week after giving birth. She considered follow-up appointments of care as a significant aspect of ongoing breastfeeding support and described those appointments as a way of

188 being in continual contact with the women, which enabled her to determine any changes in breastfeeding:

“As a midwife, I have two appointments for the women after childbirth. One at the second week and the other one at six weeks after childbirth. These appointments help to provide ongoing support to the women and identify any changes in breastfeeding.” (Midwife 4)

This sub-category revealed that the majority of the women believed that healthcare professionals ignored breastfeeding support. They believed that healthcare professionals lacked empathy, did not provide support even when requested, showed unsupportive and negative behaviour and redirected breastfeeding women to older family members. The data also revealed that healthcare professionals did not support the women during breastfeeding for various reasons, such as: not considering breastfeeding to be part of their duties and that it was, instead, the duty of older family members as part of the cultural practice within the Omani context; the women having previous experience of breastfeeding; a shortage of staff; their workload; lack of training; short hospital admissions; breastfeeding support not being part of their job description; and a lack of breastfeeding rooms within the healthcare institutions. In contrast, a few of the healthcare professionals provided breastfeeding support to breastfeeding women by assessing the women’s needs, providing verbal feedback, offering practical advice, and talking with the women about their breastfeeding experience during follow-up appointments. However, this support was restricted by the time available and the crowded conditions of the work within the healthcare institutions.

6.4 Summary

This chapter indicated a lack of breastfeeding support for women during the breastfeeding period in two main respects: lack of ongoing support from family members and a lack of healthcare professionals’ support. This category revealed that family members’ support was provided for up to the first six weeks after childbirth but did not extend beyond that period. The breastfeeding women and healthcare professionals believed that support for six weeks was not enough. They identified that breastfeeding women need support for more than six weeks after childbirth. In contrast, according to older family members, support for six weeks was enough because they wanted their daughters to depend on themselves for breastfeeding and other activities after that period. In addition, many healthcare professionals did not support women after childbirth because they believed

189 that breastfeeding support was not their role; it was, instead, the grandmothers’ role. Many other factors also affected breastfeeding support within the healthcare institutions, such as staff shortages and a lack of training, as mentioned above.

The impact of the lack of breastfeeding preparedness due to women’s expectations and the lack of support after childbirth on women’s breastfeeding experiences is discussed in the following chapter.

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Chapter Seven: Breastfeeding Journey

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Breastfeeding Journey

7.1 Overview

As indicated in chapter five, the women in this study perceived breastfeeding as the mother’s responsibility and they understood breastfeeding as a natural process. Others relied on their previous experience. This understanding gave women false expectations: they believed they would be able to breastfeed without difficulty, but this was not the case. Women generally felt unprepared for breastfeeding. They also lacked breastfeeding support, either from family members or healthcare professionals, as mentioned in chapter six. The impact of the lack of preparedness and lack of support is explored in this chapter. This chapter explores women’s early experiences of breastfeeding up to six weeks after childbirth. It also examines the difficulties women experienced with breastfeeding following the six-week period after childbirth and the impact of this on breastfeeding.

This category is composed of two sub-categories: early breastfeeding experiences and women’s ability to breastfeed. The following sections present the two sub-categories in detail.

7.2 Early Breastfeeding Experiences

This sub-category reflected the women’s early breastfeeding experiences during the six weeks after childbirth. Early breastfeeding was considered a challenging experience for a significant number of the women who participated in the research because breastfeeding was not in accordance with their expectations and some had never breastfed before. For the majority of the women, their early breastfeeding experiences were difficult. Only Star and Muluk, both of whom are multigravida women, identified their early breastfeeding as not being a difficult task. Both women spoke of how their baby latched onto the breast directly, which seemed natural and instinctive. They described their breastfeeding experiences using phrases such as ‘natural process’, ‘satisfying’, ‘happy’ and a ‘special moment’ for them and their baby. In the statement below, for example, Star states that she did not experience any difficulties while breastfeeding her previous babies. She expressed how satisfying it was to breastfeed her current baby and that her baby latched on straight away and breastfed well:

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“Breastfeeding is a natural process, I breastfed all my three daughters for more than one year…I was satisfied when my baby was breastfeeding well from my breast. I was happy. It was a special moment for me and my baby.” (Star, MG: 4 months, 2nd Interview)

Muluk also did not experience difficulties with breastfeeding her previous baby and she described her current experience of putting her baby to her breast as a joyful one. Although she encountered some difficulties at the beginning of breastfeeding when positioning her baby towards her breast, she still believed that breastfeeding was an instinctive and natural process, describing her baby’s easy attachment to the breast and ability to breastfeed. For Muluk, the initial breastfeeding was an “achievement”:

“I breastfed my previous baby well before one year…For this baby, initiating breastfeeding was fine with me because I did not struggle for a long time, and my baby started breastfeeding well. I had some problems with breastfeeding positioning, but still, I breastfed and I was happy when I was breastfeeding my baby…It was like an achievement for me, and it was a natural process.” (Muluk, MG: 4 months, 2nd Interview)

Only those two multigravida women reported that their early experiences of breastfeeding were of a ‘natural process’, ‘satisfying’, ‘happy’, a ‘special moment’ and an ‘achievement’. Other multigravida women reported that their experiences of early breastfeeding were difficult. Many of the multigravida women faced difficulties with breastfeeding positioning and attachment. When asked about their previous breastfeeding experience, they reported that they had used a birth spacing method for several years; as a result, they did not remember how to position and attach their baby towards the breast. For example,

“I needed to remember breastfeeding positioning and how to hold my baby properly because I forgot how to breastfeed and how to attach my baby towards my breast…Yes, I have experience of breastfeeding, but I forgot…I gave birth to my previous baby five years before, so I need to remember how to breastfeed again…I used one of the birth spacing methods for five years and I forgot how to breastfeed.” (Somi, MG: 4 months, 1st Interview)

Other multigravida women reiterated that breastfeeding was difficult for them and they had even encountered difficulties with breastfeeding their previous baby, as recounted by Rose in the next excerpt:

“Breastfeeding is difficult, I was struggling while breastfeeding my baby, he is not holding my breast well, I did not know what to do that time…even with my previous baby, I had difficulties with breastfeeding, breastfeeding is not easy, it is difficult.” (Rose, MG: 2 months, 2nd Interview)

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From the excerpts above, the data show that the use of birth spacing methods over a long duration had affected the current breastfeeding experiences of the multigravida women because they had forgotten breastfeeding positioning and attachment. Women with previous breastfeeding difficulties also experienced issues with breastfeeding their current baby.

It was also revealed that all the primigravida women discovered that breastfeeding was not in accordance with their expectations. They experienced early difficulties with the practical aspects of breastfeeding. For example, Moon talked about the difficulty of positioning and attachment and the need to reposition her baby in order to gain the proper breastfeeding position. She also described the efforts she was making to achieve the correct position for breastfeeding, such as using a pillow to support the baby during breastfeeding and elevating her legs on a small table. These strategies helped her overcome her difficulties with breastfeeding positioning, as she refers to below:

“After birth, I discovered that breastfeeding was difficult…I struggled a lot with breastfeeding…I did not know what I have to do, I was trying to breastfeed my baby but I did not know how to put my baby towards my nipples...My baby was not holding the breast by his mouth…I was trying several times to breastfeed correctly…I tried to position my baby to my breast and I used a pillow to support my baby and a small table to support my leg.” (Moon, PG: 3 months, 2nd Interview)

Other women, whether they were primigravida or multigravida, considered breastfeeding as a new experience for them. Breastfeeding was a new experience for women from different perspectives. The primigravida women described breastfeeding as something they were doing for the first time, as they had never breastfed before. For example, Anwar struggled because she did not know how to hold her baby properly for breastfeeding:

“I did not know how to hold my baby for breastfeeding. Breastfeeding was a new thing that I did not do before.” (Anwar, PG: continued BF more than 4 months, 1st Interview)

It was not only the primigravida women who regarded breastfeeding as something they were doing for the first time, as the multigravida women had a similar view. Multigravida women identified that they were dealing with the current breastfeeding experience as a new one. This perception was due to their belief that ‘each baby has his own way of breastfeeding’ and ‘for each baby, there is a new story and a new experience’. They believed that each breastfeeding experience had a different struggle. According to the multigravida women, they had overcome the previous difficulty of breastfeeding only to

194 face a new challenge in breastfeeding their current baby. For example, Rose commented that she had had breast engorgement during her previous breastfeeding experience and thus knew how to solve that particular difficulty; however, for the current breastfeeding, Rose faced a problem with sore nipples and she did not know how to solve her current difficulty. Rose thought that this time she would be better able to breastfeed, but she faced difficulties with breastfeeding because she did not know how to manage with sore nipples:

“Breastfeeding is not a new experience for me, I have previous experience of breastfeeding, but it is not the same. I thought that I would do better this time with breastfeeding, but it is not easy, even with this baby. Each baby has his own way of breastfeeding. I feel that for each baby, there is a new story and a new experience…In the previous breastfeeding experience, with my daughter, I had breast engorgement and I knew how to solve that problem, but this time I have sore nipples and I do not know what to do for this problem.” (Rose, MG: 2 months, 2nd Interview)

The multigravida women believed that each breastfeeding experience has its own struggle. As a result, Rose expressed the view that she needed to learn about breastfeeding challenges during the first pregnancy, as mentioned in section 5.5 (Lacking Preparedness for Breastfeeding).

It would appear in the light of the women’s reports that the most challenging part of the breastfeeding experience was the physical pain accompanying breastfeeding, which caused the women discomfort. As a result, the women tried to seek help and treatment from healthcare professionals in the health centres; some of them were being treated for a few weeks, such as with lanolin ointment. For example, Moon had sore nipples during the early breastfeeding experience and the midwife referred her to the doctor for treatment. In the next excerpt, Moon expresses her painful experience with sore nipples and how a midwife did not care about her difficulty with breastfeeding during the follow- up appointment in the postnatal clinic:

“Breastfeeding is a painful experience. I was in pain when I was breastfeeding my baby in the hospital and at home as well…I could not tolerate the pain; thus, I went to the health centre for follow-up care in the second week after my birth, and I asked the midwife the reason why I had pain while I was breastfeeding and I was worried. The midwife did not say anything to me, and she just referred me to see the doctor. She did not explain about sore nipples, she just told me that I have to go to see the doctor. The doctor told me that I had sore nipples and she gave me treatment like ointment…still I am on treatment.” (Moon, PG: 3 months, 1st Interview)

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It emerged from the research that it was not only primigravida women who suffered from sore nipples; multigravida women also had the same difficulty. For example, Sweet, a multigravida woman, explained that she faced a problem with sore nipples in the early breastfeeding experience and she did not understand the reasons for developing this soreness. Thus, Sweet sought treatment, as she recounts in the next excerpt:

“I developed sore nipples one week after my birth…I had sore nipples, and I was in pain while breastfeeding. I did not know why I had sore nipples. I am on treatment for two weeks now.” (Sweet, MG: 2 months, 2nd Interview)

During probing, Sweet was asked if she had sought help from her mother for her early problem with sore nipples. She stated that her mother asked her to go to a doctor for treatment:

“Yes, I asked my mother to help me or find some treatment for the sore nipples but she told me to go to the doctor.” (Sweet, MG: 2 months, 2nd Interview)

I also asked older family members about interventions when their daughters suffered from sore nipples. Rose’s mother-in-law replied that she asked her daughter to seek medical advice, as referred to in the following statement:

“If my daughters had sore nipples, I asked them to go to a doctor and ask for their treatment.” (Mother-in-law 1)

From the excerpts above, it can be seen that older family members did not know how to manage sore nipples; as a result, they asked their daughter to seek medical advice for their problem.

Although some multigravida women did not know the reason for developing sore nipples, others did understand what caused it. For example, Rose found that her baby’s poor latching affected her so much that she experienced severe pain during breastfeeding and one of her nipples was bleeding. Consequently, she was uncertain about her ability to continue breastfeeding:

“I was struggling with breastfeeding after my birth. My baby was not holding my breast correctly…I developed sore nipples again, and one of my nipples bleeds. I am in pain while I am breastfeeding…it is difficult to breastfeed my baby, I do not know if I will be able to continue breastfeeding.” (Rose, MG: 2 months, 2nd Interview)

Safi, a mother of two (a two-year-old child and the current baby), reported that she was experiencing pain while trying to manage her difficulty with inverted nipples before feeding her current infant. She had not experienced this difficulty during the previous

196 breastfeeding experience. According to Safi, during the antenatal period, the midwives did not perform a breast examination; thus, Safi did not know that she had inverted nipples before childbirth. She only recognised this difficulty after starting breastfeeding and she could not breastfeed her baby because she was experiencing pain. Safi’s mother had tried to help her by advising her to use the Hoffman technique (an exercise to help the nipples to rise). With her mother’s help, Safi was able to breastfeed her baby but was in pain:

“I did not know that I have inverted nipples because no one told me during the antenatal care...No, the midwives did not do a breast examination for me before birth. I knew that I have inverted nipples after birth…My mother was helping me to pull my nipples up and down but it was painful…I had to do that before every breastfeeding.” (Safi, MG: 4 months, 2nd Interview)

Although Safi had inverted nipples, she breastfed her baby for four months. According to Safi, she stopped breastfeeding because she returned to work, not because of inverted nipples:

“Even though I had inverted nipples, I breastfed my baby for four months…I stopped breastfeeding because I returned to my work.” (Safi, MG: 4 months, 5th Interview)

Upon further probing, Safi acknowledged that in her previous breastfeeding experience, she did not breastfeed her baby because she had a caesarean section and it was difficult for her to breastfeed. She had provided artificial milk for her previous baby:

“Actually, for the previous baby, I did not breastfeed because I had a caesarean and it was difficult for me to sit down to breastfeed my baby…The midwives started artificial feeding for my baby, and I continued with artificial feeding.” (Safi, MG: 4 months, 2nd Interview)

Safi added that she was trying to solve the difficulty of her inverted nipples with her mother’s support. Her mother guided her in how to apply massage to her nipples before breastfeeding. She also used an electronic breast pump to solve her problem. She had read on the internet that a breast pump could help to solve the problem of inverted nipples, so she used a breast pump to help the nipples come out. However, using a breast pump did not resolve her problem with pain:

“My mother taught me to massage the nipple before breastfeeding…I was searching on the internet, and I read about inverted nipples and some intervention that might help to make the nipple move up. I found that a breast pump is good to pull my nipple to the outside, but I could not tolerate the breast pump. It was painful…I don’t know if I will continue breastfeeding.” (Safi, MG: 4 months, 2nd Interview)

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From the above statements, although Safi was a multigravida woman, it appears that she not only had difficulties with breastfeeding due to physical discomfort, but also because breastfeeding was a new experience for her.

Just as Safi reported doing, other women overcame their initial breastfeeding difficulties with the help of their mother. According to the women, they experienced difficulties because they did not know how to hold their baby to initiate breastfeeding. For example, Nada supported her baby’s head to initiate breastfeeding instead of the shoulder, but she overcame this difficulty with her mother’s guidance, as described in the following excerpt:

“My mother was with me up to today teaching me and guiding me for breastfeeding, because of her help and education, I am still breastfeeding my baby…I did not know how to hold my baby for breastfeeding, I was supporting the head and my mother taught me to support the shoulder of my baby.” (Nada, PG: continued BF more than 4 months, 2nd Interview)

From the above excerpts, it seems that the women were able to breastfeed for six weeks after childbirth due to their family’s support, as mentioned in the previous chapter (Breastfeeding Support).

Women’s difficulties while breastfeeding in the early stages were witnessed during the clinical observations in the labour room, the postnatal ward and during follow-up care visits at the second and sixth weeks after childbirth.

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Early breastfeeding experience

During the clinical observations at different maternity units in the selected healthcare institutions, I observed that women’s early breastfeeding was difficult for them, when putting the baby towards their breast. They were tired while attempting to find a good position. The grandmothers were helping their daughters in the labour room and postnatal ward. I did not observe any midwives or nurses in the labour room or the postnatal ward talking with the women about their breastfeeding experiences. During the clinical observations, when I was observing the contact and communication between the healthcare professionals and postnatal women immediately after childbirth, I did not observe any communication about breastfeeding experiences. I observed that the postnatal women were trying to get support from the healthcare professionals; however, the healthcare professionals were asking the grandmothers to support the women during the early breastfeeding experiences. (Observation field notes)

This sub-category demonstrates that early breastfeeding was a natural process, and ‘satisfying’, ‘happy’, a ‘special moment’ and an ‘achievement’, for only two of the multigravida women. For the majority of the women, whether primigravida or multigravida, early breastfeeding experiences were considered challenging due to difficulties with positioning and attachment and breastfeeding being a ‘new experience’ and physically uncomfortable. The women overcame their early difficulties with breastfeeding with direction from their mother and thus were able to breastfeed during the first six weeks postnatal because the women lived with their mother. However, six weeks after giving birth, the majority of the women faced difficulties with breastfeeding and did not know how to manage those problems. As a result, the majority of the women were uncertain about their ability to continue breastfeeding their baby. In brief, as explained in the first category, Breastfeeding expectations, the lack of preparation for breastfeeding before childbirth had affected the women’s ability to breastfeed.

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7.3 Women’s Ability to Breastfeed

This sub-category, Women’s ability to breastfeed, describes women’s breastfeeding experiences after the six weeks following childbirth. Difficulties with breastfeeding continued for the majority of the women after six weeks following the birth. Breastfeeding difficulties were due to conflicting needs, work commitments, physical discomfort, perceptions of insufficient milk production, and breastfeeding in public, which affected their ability to breastfeed their baby. The women’s intentions regarding the length of time they would breastfeed did not match their actual breastfeeding period. For example, of the eleven women who participated in the interviews, three had intended to breastfeed for two years; however, one of the women stopped breastfeeding three months after giving birth, and two ceased four months after childbirth. There were different reasons for breastfeeding cessation, such as sore nipples and returning to work. Only three of the eleven women were able to continue breastfeeding up to the end of the data collection period, which was four months. (See Table 4.1 for the women’s intentions regarding breastfeeding, the actual duration of breastfeeding and reasons for breastfeeding cessation.)

7.3.1 Conflicting needs After six weeks postnatal, some of the women, especially non-working women, reported that they were undertaking a lot of housework during the day, which made them feel too tired to breastfeed their baby at night. For example, Sweet, who had intended to breastfeed for six months, stopped breastfeeding in the second month after childbirth, stating that one of the reasons was housework. She was breastfeeding her baby during the day and trying to do housework at the same time. According to Sweet, no one was helping her with the housework because her husband had work commitments and her mother-in-law had a health problem. The six weeks of help had also stopped, so Sweet felt tired and overloaded. She could not tolerate this and did not breastfeed her baby at night because she needed to sleep. Sweet was not able to continue breastfeeding and started using artificial milk at the end of the second month after childbirth:

“I have a sore nipple, and it was painful. Also, I have to do the housework…I was tired from doing housework. I had to do everything in the house…I was tired. I could not breastfeed at night because I was tired and wanted to sleep, this is too much and I could not tolerate it, so I stopped breastfeeding, and I started artificial feeding.” (Sweet, MG: 2 months, 3rd Interview)

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Many of the women who worked experienced conflict between breastfeeding and the need for sleep. They had appreciated the support of their family for up to six weeks but the women commented that their family’s support after six weeks was limited during their working hours. For example, Somi stated that after working hours she had to take care of her baby and breastfeed him. As a result, she felt exhausted and wanted to sleep at night. According to Somi, she could not tolerate breastfeeding at night because she was tired and thus stopped breastfeeding four months after giving birth:

“I appreciated the support from my family, especially when I returned back to my work, but I need more support because after I returned from my work, I had to take care of my baby and to breastfeed. I felt tired because of the nature of my work and I became more tired when I was breastfeeding my baby after returning from my work, so I could not breastfeed at night because I was tired and I wanted to sleep...this was too much, I could not tolerate this situation and I stopped breastfeeding after four months.” (Somi, MG: 4 months, 4th Interview)

From the excerpts above, it can be seen that Sweet and Somi stated, respectively, that “this is too much and I could not tolerate it” and “this was too much, I could not tolerate this situation”. This suggests that they were in a stressful situation due to physical exhaustion from housework and working outside the home; as a result, they stopped breastfeeding and provided artificial milk for their baby.

During the interviews with older family members, they were asked if they helped the breastfeeding women with housework after six weeks postnatal. One of the seniors replied that she had a health problem and she is now older. She felt that she had performed her duty as a mother and that it was now the turn of the young women to do their duty. She added that after six weeks from the birth, she was helping her daughters by taking care of their baby and helping them according to her ability, as described by Muluk’s mother in the next excerpt:

“I cannot help in housework because I am sick. I have a back problem, and I have hypertension and am diabetic. I am an older woman, and I cannot work like before…I did my role as a mother, and now it is their turn [her daughters], but I am helping them to take care of their baby and sometimes helping them when I can, especially when my daughters go back to their work.” (Grandmother 3)

Some of the women experienced conflicts between breastfeeding and the need for sleep, especially at night, due to housework and having returned to work. They could not tolerate a situation in which they were exhausted, which had affected breastfeeding, especially at night. As a result, they stopped breastfeeding.

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7.3.2 Work commitments All the working women who took part in the research stopped breastfeeding after they returned to work. Some of the working women planned to use a breast pump before going to work. Although the working women used a breast pump for a few days after re-starting work, they did not continue to use one because they felt tired. They also felt stressed because they were worried about being late for work. As a result, they could not breastfeed their baby and started using artificial milk. Safi represented the overall view of all the working women when she stated:

“I planned to use a breast pump and to give my baby my milk…I thought it will be easy but no, it is difficult…I was using an electronic breast pump before going to my work, it was very tiring because I got up in the early morning and I spent a long time using the electronic pump. I felt stressed because I was worried about being late for work...I could not tolerate that, so I started giving my baby artificial milk.” (Safi MG: 4 months, 5th Interview)

Somi added in the following quotation that she could not breastfeed when she returned to work because she wanted to sleep at night:

“It is difficult to breastfeed at night, I wanted to sleep. If I breastfed at night, I will not go to my work, it is difficult really.” (Somi, MG: 4 months, 4th Interview)

Three of the working women (Muluk, Somi and Safi) stopped breastfeeding when they returned to work and then gave artificial milk to their baby. It seems that the working women felt stressed and overloaded when they returned to work due to physical tiredness and feeling stressed about being late for work and conflicting needs (e.g., wanting to sleep at night).

7.3.3 Physical discomfort Star, a working woman, did not experience any difficulties during breastfeeding, either with her previous babies or the current one. She breastfed all her previous babies up to eighteen months; however, she struggled with the current breastfeeding because of the pain that she had two months after childbirth. She had a health issue with her breast (breast lump) and, as a result, stopped breastfeeding four months after giving birth, as advised by her doctor:

“I know how to breastfeed because I breastfed all my daughters for one and a half years. I was breastfeeding my daughter even when I had work responsibilities, I used a breast pump and my mother was feeding them until I returned from work and after work I was breastfeeding them…but for the current baby, I could not

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breastfeed two months from my birth because of pain, I could not tolerate the pain that I had and the doctor advised me to stop breastfeeding.” (Star, MG: 4 months, 4th Interview)

Rose, another working woman, reported that she also stopped breastfeeding because of sore nipples and the associated pain at the end of the second month. She then gave artificial milk to her baby as a method of reducing the physical discomfort that she was feeling:

“When my baby was breastfeeding, I had severe pain in my nipples, I could not tolerate the pain, so I stopped breastfeeding…and I gave my baby artificial milk.” (Rose, MG: 2 months, 3rd Interview)

In addition to the physical exhaustion from housework referred to above, Sweet also stopped breastfeeding because of the pain associated with sore nipples:

“I also stopped breastfeeding my baby because of the pain, I could not tolerate the pain anymore.” (Sweet, MG: 2 months, 3rd Interview)

Some of the women stopped breastfeeding due to feelings of pain and the physical discomfort associated with sore nipples. Sweet stopped breastfeeding for more than one reason: conflicting needs and the pain associated with sore nipples.

7.3.4 Perceptions of insufficient milk production Before childbirth, several of the primigravida women believed that milk production would occur naturally and adequately. After childbirth, the women felt uncertain of whether their baby was getting enough milk, especially when their child was crying. Before childbirth, many of the women understood that they would have enough milk for their baby; after childbirth, however, their experience was the opposite and they felt that they had insufficient milk production. The women then tried everything possible to increase their milk supply. For example, Noor ate Omani food, which contains fenugreek, to increase her milk production as this is a traditional practice in Oman. She also sought advice from her mother, who told her to continue breastfeeding. However, Noor went against her mother’s advice and introduced artificial milk to her baby at the end of the third month, although she was alerted by her mother not to give artificial milk. In addition, she did not seek help from the midwife because she thought that her milk would come with time. Noor described her situation as follows:

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“My baby was crying when I was breastfeeding. He was hungry…I did not know if my breasts make enough milk for my baby…I asked help from my mother and she told me to breastfeed more, so milk will come more…I did not ask help from the midwives for this problem because I thought that milk would come with time…I was also eating Omani food to increase milk production because my mother told me to. My mother told me not to give artificial milk to my baby, but I could not see my baby crying, I was worried about my baby, so I started artificial feeding.” (Noor, PG: 3 months, 4th Interview)

It was revealed that both primigravida and multigravida women believed that their babies were crying due to insufficient milk production. For example, Sweet, who had sore nipples, added that she was afraid of hearing her baby crying because she knew it indicated a need for feeding; thus, she guessed that her baby was not receiving a sufficient amount of milk:

“My baby was crying too much. I was afraid from the way of his cry. I was afraid that he was not getting enough milk…I knew that he was crying for milk.” (Sweet, MG: 2 months, 2nd Interview)

Noor also believed that she did not have sufficient milk because her baby’s weight decreased; as a result, she provided artificial milk for her baby at the end of the third month. From Noor’s excerpt, it seems that she did not know that the baby’s weight could decrease even with exclusive breastfeeding:

“I did not have enough milk…my baby was crying too much and my baby’s weight reduced, I was really worried about my baby, so I gave artificial.” (Noor, PG: 3 months, 4th Interview)

From the excerpts above, it can be seen that the baby crying and a reduction in the baby’s weight had affected the women’s experience of breastfeeding revealing a knowledge gap about breastfeeding. The women felt worried and anxious about their baby’s health and thought that they did not have enough milk. In this study, only one woman, Noor, stopped breastfeeding in the third month after childbirth due to her perception of insufficient milk production.

During the interviews with older family members, Star’s mother provided expert knowledge of the importance of continuing breastfeeding to increase milk production. She emphasised the significance of continuing breastfeeding to produce more milk. According to her, none of her daughters had complained about insufficient milk production during the breastfeeding period. The view of Star’s mother was evident in Star’s narratives; Star did not comment on insufficient milk production and she was breastfeeding her baby without difficulties:

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“Women need to breastfeed only. If the women keep breastfeeding, more and more milk will come. All my daughters breastfed their baby for more than one year…They did not complain about milk production because they continued breastfeeding.” (Grandmother 2)

The majority of the primigravida women lacked information before childbirth regarding the amount of milk their baby would need. However, Nada knew that her baby only needed a small amount of milk after childbirth; thus, she was satisfied with her milk production. According to Nada, she obtained information about the amount of milk needed for a baby by listening to a health education session conducted by nursing students in one of the health centres during follow-up appointments after childbirth. Before childbirth, Nada believed that a baby needed a large amount of milk, but she was surprised by the health education sessions stating that a baby needs only a small amount of milk in the first few weeks:

“I thought my baby would need a large amount of milk after birth but when I went to the health centre during my visit at forty days, by chance, I was listening to student nurses who were presenting information about breastfeeding…they talked about the amount of breast milk needed for a baby and I was really shocked by the small amount of milk needed by a baby…they showed the amount of milk in a syringe, it was a very small amount.” (Nada, PG: continued BF more than 4 months, 5th Interview)

Although the primigravida women were unaware before the birth of the amount of milk needed for their baby, the multigravida women were aware of the amount of milk required before they gave birth, as indicated in the next excerpt:

“Yes, I knew that my baby needs a small amount of milk and this amount is increasing with the baby’s growth, I breastfed before, and I knew that.” (Muluk, MG: 4 months, 4th Interview)

7.3.5 Breastfeeding in public Another aspect of the difficulties of breastfeeding was breastfeeding in public. It was not surprising that many of the women automatically raised this issue when asked about cultural aspects related to breastfeeding. Breastfeeding in public is not allowed in Omani culture because it is not acceptable for women to expose their breasts in front of males other than their husband. Islam also forbids women to expose any part of their body in front of male strangers. The matter is not related to breastfeeding as such but does have an impact upon it. As a result, many of the women described breastfeeding in public as challenging. For example,

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“It is difficult to breastfeed in public…we cannot breastfeed in front of males…it is our culture and it is not nice to expose our breast in front of male strangers…as a Muslim, it is forbidden for women to expose their body in front of male strangers, so it is difficult to breastfeed in public.” (Star, MG: 4 months, 3rd Interview)

Some of the primigravida women talked about how they feel when they expose something that is private. For example, Nada, a primigravida woman, was breastfeeding for the first time and she felt shy about exposing her breast while breastfeeding. As a result, she did not feel comfortable about breastfeeding her baby, even in front of female strangers. However, Nada was comfortable about breastfeeding her baby in front of her mother. She also reported that it felt fine to breastfeed her baby in front of healthcare professionals if they wanted to teach her about breastfeeding:

“I felt shy to breastfeed in front of others. I felt shy to expose my breast because this is the first time for me...I did not want to breastfeed in front of others…It was okay to breastfeed in front of my mother but not in front of strangers…If the midwives want to teach me about breastfeeding, it is okay to breastfeed in front of them.” (Nada, PG: continued BF more than 4 months, 2nd Interview)

While the primigravida women felt shy about exposing their breast during breastfeeding in front of female strangers, the multigravida women did not want to breastfeed in front of female strangers due to a worry regarding envy. Envy is present when a person harms another because of the ‘evil eye’. It begins when a person desires something, then his/her evil feelings influence it by repeatedly staring at the object of envy with a feeling of jealousy. Allah ordered his prophet, Muhammad (Peace Be Upon Him), to seek shelter with Him from the envier. The data revealed that some of the women believed in the negative power of envy. For example, in the following excerpt, Star explains that she avoided breastfeeding in public because of negative energy, such as envy. She expresses her worry about breastfeeding in front of female strangers, as she does not want them to envy her and her baby:

“I am afraid of the evil eye [envy], so I do not breastfeed in front of strangers. I only breastfeed in front of my family members, only female family members.” (Star, MG: 4 months, 3rd Interview)

However, other multigravida women reported that they were comfortable with breastfeeding in front of female strangers, as illustrated by Muluk in the following excerpt:

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“It was okay to breastfeed in front of the women in my family, and other women who are not my family [female strangers].” (Muluk, MG: 4 months, 3rd Interview)

In addition, many of the women stated that their husbands did not encourage them to breastfeed in public because they did not want another male to see their wife’s breasts. Instead, those husbands encouraged their wives to breastfeed inside the house, as demonstrated in the next two excerpts:

“My husband was encouraging me to breastfeed at home…My husband did not allow me to breastfeed in public and he advised me to cover my breasts if I needed to breastfeed in public.” (Noor, PG: 3 months, 3rd Interview)

“He [her husband] told me not to breastfeed outside the house.” (Somi, MG: 4 months, 4th Interview)

Many of the women expressed difficulty in finding private spaces in public areas in which to breastfeed their baby. According to the accounts, there were no private places for women to breastfeed, even in the health centre. Consequently, they preferred to stay at home to breastfeed their baby. In the next statement, Anwar describes the difficulties of breastfeeding in public:

“It is difficult to go out with my baby. I cannot do any social activities, like visiting my family or walking because I have to breastfeed my baby, I preferred to stay at the house...when I go to the health centre with my baby, I feel it is difficult to breastfeed there because it is an open place and men can enter the waiting area, so I have to be careful when breastfeeding. It is difficult to breastfeed in public.” (Anwar, PG: continued BF more than 4 months, 5th Interview)

Other women reported that they used their scarf to cover their breast when breastfeeding in public. For example, Muluk stated that she used her scarf to cover her breast when breastfeeding at the healthcare centres during the follow-up appointments and she was as careful as possible while breastfeeding:

“Sometimes when I went to the health centre, I used a scarf to cover my breast during breastfeeding, and I have to be very careful…It was difficult to breastfeed in public.” (Muluk, MG: 4 months, 4th Interview)

Furthermore, in order to find a private space in which to breastfeed their baby, the women had to stop what they were doing and find somewhere else. For example, Moon reported that she often left a shopping area to find a place in which she could breastfeed. This situation was difficult for her because she had to go to the parking area to breastfeed her baby in her car:

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“There was no private place to breastfeed in public, especially in the shopping areas or hospitals, so I have to leave my shopping or anything that I am doing or leave my family to go to the parking area to breastfeed my baby in my car.” (Moon, PG: 3 months, 3rd Interview)

Consequently, many of the women preferred to stay at home because they could not manage the challenges associated with breastfeeding in public. For example, Star explained that she was isolated from social activities because she experienced a dilemma when wanting to go for a walk, visit her family or go shopping. She was worried that she would have nowhere to go if her baby wanted to breastfeed. She could not imagine that she would feel comfortable in the car breastfeeding her baby; thus, she preferred to stay at home:

“I cannot go shopping or visit my family because it is difficult to breastfeed outside the house, so I preferred to stay in the house to breastfeed my baby. I felt that I am isolated from people...I cannot breastfeed my baby in the car.” (Star, MG: 4 months, 4th Interview)

Breastfeeding in public was challenging for the majority of the women because they did not want to expose their breasts. The women in the study constructed their beliefs about breastfeeding in public from the Omani culture and the Islamic religion. Many of the women did not want to breastfeed their baby in front of female strangers either, due to feeling shy and wanting to avoid others’ envy; however, other women felt comfortable with breastfeeding their baby in front of female strangers. In addition, the women’s husbands did not encourage their wives to breastfeed in public because they did not want another male to see their wife’s breasts. It can also be seen that the majority of the women found it difficult to breastfeed in public due to a lack of private places for breastfeeding women; as a result, many of the women preferred to stay at home to breastfeed their baby. In brief, breastfeeding in public was not encouraged for the women in this study.

This section has revealed that the majority of the women in this study stopped breastfeeding due to exhaustion, physical discomfort, their baby’s behaviour or a reduction in their baby’s weight. The data also showed that breastfeeding in public was not encouraged for the women for many reasons, such as not wanting their breasts to be exposed, which is recommended in Islam, feeling shy, worrying about envious people, their husband’s discouragement, and the lack of private places in which to breastfeed when in public.

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7.3.6 Dealing with social role expectations The interviews revealed that the women had no choice about breastfeeding and they had to breastfeed. Thus, during the interviews, the women were asked how they dealt with expectations of the role (breastfeeding as a mother’s responsibility). Women who stopped breastfeeding believed that they had to find reasons that would be acceptable within their society in order to stop. For instance, in the following excerpt, Safi states that if she chose not to breastfeed, she had to find a reasonable form of justification; otherwise, her mother- in-law would judge her negatively. Thus, when she could not adapt to breastfeeding difficulties, she considered that her return to work would a good reason for her to stop breastfeeding:

“I know that I have to breastfeed my baby because I am a mother, all my family members were asking me to continue breastfeeding, but I felt tired of breastfeeding, I could not cope, especially when I returned from my work…I could not say ‘No, I will not breastfeed my baby’. My family members, especially my mother-in-law, would say that I did not do my best to breastfeed my baby, I am worried about being judged, thus, I have to have a reasonable reason to stop breastfeeding and returning to work was a good reason...returning to my work is my reason to stop breastfeeding, I have a good reason to stop breastfeeding… Women will talk about me if I stopped breastfeeding without a reason.” (Safi, MG: 4 months, 3rd Interview)

Muluk’s mother also emphasised the same notion and stated:

“Women can stop breastfeeding if they have reasons. For example, sick women can stop breastfeeding their babies…also working women can stop breastfeeding their baby.” (Grandmother 3)

One woman was worried about her baby’s health due to the baby’s crying and the reduction in his weight. Noor believed that her insufficient milk production was a good reason to stop breastfeeding, particularly when her baby’s weight decreased. As a result, she stopped breastfeeding and replaced this with artificial milk:

“All are asking me to breastfeed my baby, but my baby was only crying for no apparent reason; I did not understand what to do with him…I was afraid of others’ judgement and I was worried about my baby…I wanted to breastfeed but I felt I was not able to breastfeed because of his crying, I could not cope...I was worried about my baby’s weight. My mother told me to continue breastfeeding, and I was breastfeeding, but my baby’s weight was not increasing. His weight was too low, so I stopped breastfeeding, and I gave him artificial milk…I wanted to breastfeed but I have a reason to stop breastfeeding.” (Noor, PG: 3 months, 4th Interview)

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Muluk’s mother emphasised the same notion:

“Women cannot stop breastfeeding like that without reason, otherwise, they are not good mothers…yes, if they have reasons, then no problem, they can stop breastfeeding, it is accepted…if babies had a problem and they cannot breastfeed, yes the women can give bottle feeding…if the babies’ weight does not increase, women can give bottle feeding to help the babies to grow.” (Grandmother 3)

Other women had physical or health reasons to stop breastfeeding. For example, in the next excerpt, Moon reports that her sore nipples were her reason to stop breastfeeding:

“My mother was always asking me to breastfeed my baby but I had pain and I cannot breastfeed my baby with sore nipples, so my mother told me to stop breastfeeding because of the pain that I have, I stopped breastfeeding for this reason.” (Moon, PG: 3 months, 4th Interview)

Star added the following to her account:

“My breast condition had affected my ability to breastfeed my baby…I do not want my husband’s family to judge me negatively...they were asking me to breastfeed my baby, I do not want to hear any negative words from them about my breastfeeding...I heard my mother-in-law when she was talking negatively about my sister-in-law when she stopped breastfeeding; thus, I was trying to avoid that, but now, they knew that I have a problem with my breast and they knew that I cannot breastfeed my baby, so I have a reason to stop breastfeeding.” (Star, MG: 4 months, 5th Interview)

Breastfeeding was not optional and the women in this study knew that they had to breastfeed because they had no choice. The data revealed that lack of preparedness before childbirth had affected the women’s ability to breastfeed, which, in turn, had an effect on their resilience to overcome breastfeeding difficulties. The women did not adapt to breastfeeding difficulties and thus stopped breastfeeding. The women were worried and feared being judged negatively if they stopped breastfeeding; thus, in order to stop breastfeeding, they had to find socially acceptable reasons. Many of the women believed that returning to work, insufficient milk production, a decrease in their baby’s weight and the condition of their breasts were socially acceptable reasons to stop breastfeeding. In this study, of the eleven women who participated, eight stopped breastfeeding at different intervals during the first four months after childbirth.

In contrast, only three women continued breastfeeding until the end of the data collection process (four months): two of them were primigravida women and one was multigravida. Those women were asked about their reasons for continuing breastfeeding at the end of the data collection process (four months). The data revealed that those women used

210 coping strategies to overcome their breastfeeding difficulties during the first six weeks after childbirth with the help of family members. For example, in the following excerpt, Nawal, a multigravida woman, expresses her wish to breastfeed her baby and explains that, with the help of her mother during the first six weeks after childbirth, she was able to breastfeed her baby and do housework by rescheduling the sleeping time of the baby. She reported that she used the same strategy after six weeks:

“I knew that I would return to my house and I knew that my mother would not stay with me after six weeks. I wanted to continue breastfeeding…I had difficulties in breastfeeding at night, so I needed to arrange my baby’s sleeping time, I mean to sleep more at night and less during the day. My mother helped me because I asked her to help me when I was with her, so she did not allow the baby to sleep during the day for a longer duration. When I returned to my house, I did the same, it was difficult but still I was able to breastfeed and I was able to do housework…sometimes, I was sleeping during the day with my baby and this helped me to breastfeed at night.” (Nawal, MG: continued BF for more than 4 months, 4th Interview)

Another woman continued breastfeeding her baby after asking advice from women in her family who were expert in dealing with breastfeeding challenges, such as her mother, mother-in-law and sisters. She also asked other women in her family who were working in the medical field. She received help after the six weeks following the birth. In the next excerpt, Nada explains that she asked other women who had experience of breastfeeding about the difficulty she was facing and how to solve it in order to continue breastfeeding:

“I liked breastfeeding, I felt it was a beautiful experience and I felt it connected me with my baby…when I faced a problem with breastfeeding, I was asking the women who breastfed their baby and I learned from their experiences. I learned how to solve some problems with breastfeeding from other women…I was asking my mother or mother-in-law and my sisters. I also asked my sister-in-law, she is a doctor in a children’s clinic…they were helping me after 40 days [6 weeks] of my birth.” (Nada, PG: continued BF more than 4 months, 5th Interview)

It could also be seen that another woman participant not only asked her mother about the difficulties that she faced and how to solve them, but also searched on the internet for additional information during the first six weeks after childbirth:

“I was asking my mother when I had problems with breastfeeding during the forty days, and she was helping and teaching me, I also searched on the internet for more information on my problem, and I got some solutions in breastfeeding positioning.” (Anwar, PG: continued BF for more than 4 months, 4th Interview)

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Nada added to her account that she also continued breastfeeding to satisfy members of her family. According to Nada, her family were supportive of her, especially during the first few weeks postnatal. Her family members were supportive to her even after six weeks following the birth; thus, she did not want to stop breastfeeding or to replace breastfeeding with artificial milk and wanted to please her family. Nada commented that the idea of stopping breastfeeding or using artificial milk was making family members unhappy; as a result, she continued breastfeeding her baby to satisfy her family:

“My family was supporting me very much…My husband and my mother were supporting me during breastfeeding, up to today they were with me, guiding me and advising me from different aspects, so I feel shy about stopping breastfeeding, and I have this much support. I do not want to make my family sad if I stopped breastfeeding. I want to breastfeed to make my family happy.” (Nada, PG: continued BF more than 4 months, 5th Interview)

The three women who continued breastfeeding until the data collection was completed expressed their desire to breastfeed. They mentioned factors such as ‘I wanted to breastfeed’, ‘I liked breastfeeding’ and ‘I have a desire to breastfeed’; these feelings pushed the women to breastfeed despite the difficulties they experienced. For example, Anwar stated that she had a desire to breastfeed that encouraged her to continue breastfeeding her baby, as she describes below:

“I wanted to breastfeed, I have a desire to breastfeed my baby…This desire encouraged me to continue breastfeeding my baby.” (Anwar, PG: continued BF for more than 4 months, 4th Interview)

Other women had a similar desire and other supportive factors, such as a housemaid (a person who helps by doing domestic tasks), which was one of the reasons the women continued breastfeeding, as explained in Nada’s statement:

“I accepted breastfeeding my baby because I am not a working woman and I am not doing housework at my house, I have a housemaid, who does everything at the house, so I accepted breastfeeding, and I wanted to do that [breastfeeding].” (Nada, PG: continued BF more than 4 months, 5th Interview)

Nada added that breastfeeding became easier, which increased her belief in her ability to breastfeed, as she reports below:

“Now, I am breastfeeding more easily than before, and I feel that I am able to breastfeed.” (Nada, PG: continued BF more than 4 months, 5th Interview)

The three women who continued breastfeeding adapted to breastfeeding difficulties and used adaptive or coping strategies during and after the first six weeks after childbirth,

212 such as rescheduling the sleeping time of themselves, asking questions to breastfeeding experts in their family and searching on the internet for additional information about their issues with breastfeeding. The women also had the desire to breastfeed and other supportive factors, such as support from family members or a housemaid, which helped them to continue breastfeeding. Women who continued breastfeeding also believed in their ability to breastfeed because it became easier. Adaptive or coping strategies helped the women to achieve resilience regarding breastfeeding. For example, by rescheduling the sleeping time, the women were sleeping when their babies were also sleeping. This strategy helped the women to relax and avoid feeling tired, especially during breastfeeding at night. As a result, the women continued breastfeeding because they knew how to deal with breastfeeding difficulties. It is essential to mention that the women did not solve their problems with breastfeeding; instead, they adapted to breastfeeding difficulties and were resilient.

7.4 Factors in Successful Breastfeeding

The findings suggest that the three women who continued breastfeeding reached a state of resilience by possessing certain internal factors, such as a desire to breastfeed, being optimistic, searching for knowledge about breastfeeding difficulties and using coping strategies; external factors, such as having support, also helped them to be resilient. Figure 7.1 illustrates the strategies used by the women to breastfeed their baby successfully. These findings suggest that the women’s ability to breastfeed was dependent on their resilience.

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Factors in successful breastfeeding

Internal External Factors Factors

Searching Owning a Coping Having for desire/ Strategies support Knowledge optimism

Figure 7.1: Factors in successful breastfeeding

7.5 Summary

The category explored in this chapter has shown that early breastfeeding experiences were difficult for the majority of the women in this study due to positioning and attachment, breastfeeding being a new experience, and physical discomfort. The women breastfed up to six weeks after giving birth due to the support they received from their mother. Six weeks after giving birth, the women received more limited support from their family, and thus faced difficulties with breastfeeding and did not know how to manage those issues. As a result, the majority of the women were uncertain about their ability to continue breastfeeding their baby. Many of the women experienced breastfeeding difficulties after six weeks due to conflicting needs, work commitments, physical discomfort, perceptions of insufficient milk production, and problems regarding breastfeeding in public. Those breastfeeding difficulties had affected the women’s breastfeeding experience; as a result, they stopped breastfeeding due to their physical exhaustion, physical discomfort, the baby’s behaviour, a decrease in their baby’s weight, and need to return to work.

The majority of the women were not able to adapt to breastfeeding difficulties because they did not have knowledge of how to manage the problems they were experiencing with breastfeeding. At the same time, they knew that they had to breastfeed; thus, in order to

214 stop breastfeeding, they had to find socially acceptable (valid or good) reasons. The majority of the women stopped breastfeeding once they found what they perceived to be a valid reason to do so. A few of the women continued breastfeeding because they had implemented adaptive or coping strategies to overcome their breastfeeding difficulties during and after the six weeks following childbirth. The strategies helped the women to achieve resilience with breastfeeding.

The following chapter presents an in-depth discussion of the significant findings of the research, including the emergent core category and theory.

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Chapter Eight: Synthesis and Discussion

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Synthesis and Discussion

8.1 Overview

Successful breastfeeding is dependent on social, cultural, physical and psychological factors (Haghighi and Abbasi, 2015), which can influence a woman’s ability to breastfeed and continue breastfeeding. Having followed the constant comparative analysis method of constructivist grounded theory, the findings indicate that the ability of the women who participated in this study to breastfeed was dependent on their ability to adapt to breastfeeding difficulties. In this study, it appeared that women’s ability to breastfeed was affected by sociocultural, physical and psychological aspects. Before childbirth, some of the women had unrealistic expectations and believed in their unquestionable ability to breastfeed. They assumed breastfeeding would be an easy task and they would not experience any difficulties. After the birth, when the women were moving through the process of breastfeeding, they recognised the reality of breastfeeding, which was not in accordance with their expectations. The women faced difficulties with breastfeeding and did not know the practical components (i.e., how to breastfeed). Nor did they know about breastfeeding challenges and their solutions. When women experienced difficulties with breastfeeding and did not know how to manage them, they felt disappointed and became uncertain about their ability to breastfeed. Thus, the majority of the women in this study could not adapt to breastfeeding difficulties, and they stopped breastfeeding. However, a few women were able to breastfeed up to the end of the data collection process (four months).

This discussion chapter presents the emergent core category, ‘Navigating the Reality of Breastfeeding’, and an explanation of its development. The chapter also illustrates the findings, which are synthesised under two main headings: breastfeeding intention and women’s ability to breastfeed. The central issues identified are connected with the existing theories and compared with the literature. At the end of the chapter, the emergent theory, ‘Resilience: The Power to Breastfeed’, is discussed, together with its linkage with the core category.

8.2 Core Category: Navigating the Reality of Breastfeeding

A core category is “a concept that encapsulates a phenomenon apparent in the categories and sub-categories constructed and the relationship between these” (Birks and Mills, 217

2015, p. 177). Identifying the core category in a study is central to being able to combine the other categories into a theory grounded in the data (Hallberg, 2006). In this study, theoretical coding helped the process of developing the core category. Moreover, the researcher classified all the memos produced in this study according to the three categories that emerged. The researcher re-read the memos, which helped to find the linkages between the three main categories and develop a core category that captured the central meaning of the study. Each of the categories in this study contributes a portion of the explanation of the theory; thus, it was important for the researcher and the supervisory team to subsume all three categories. As such, the core category, ‘Navigating the Reality of Breastfeeding’, was developed. The researcher also reflected upon the data to find a connection between the categories by developing a number of diagrams and concept maps, an approach that was helpful in developing the core category. This process was undertaken with the guidance of the supervisory team.

The core category, ‘Navigating the Reality of Breastfeeding’, developed from the three main categories: (i) Breastfeeding Expectations, (ii) Breastfeeding Support and (iii) Breastfeeding Journey. Figure 8.1 shows the development of the core category from the three categories. In this study, the core category represents the perceptions and experiences of breastfeeding women and the perspectives of the women’s family members and healthcare professionals within the Omani context. The core category suggests that while the women were moving through the process of breastfeeding, they realised the reality of it. This reality was not in accordance with the women’s expectations. The women were surprised by this reality and were living with uncertainty and doubt.

While the women were navigating the process of breastfeeding after giving birth, they realised the reality of their expectations, the support provided by family members and healthcare professionals, and the breastfeeding experience. The women recognised that they had had unrealistic expectations with regard to breastfeeding and that there was a mismatch between the reality of breastfeeding and their previous beliefs. The reality of breastfeeding was not known to the women before childbirth. After the birth, many women experienced a lot of difficulties with breastfeeding and did not know how to deal with them. The women navigated the unknowns with a feeling of uncertainty. They encountered a diversity of new and unexpected difficulties with breastfeeding during the

218 process of breastfeeding and with those difficulties came feelings of disappointment. Many women felt confused, upset, frustrated and stressed.

Mismatch between the reality of breastfeeding and women’s expectations.

‘Navigating the Reality of Breastfeeding’

Breastfeeding Breastfeeding Breastfeeding Expectations Support Journey

Figure 8.1: Development of the core category from the three main categories

In this study, it became apparent from the excerpts from the women’s interviews that the women had had unrealistic expectations regarding breastfeeding. Such unrealistic expectations came from social norms that were acquired within the Omani context, Islamic guidelines regarding breastfeeding, and knowledge of the health benefits of breastfeeding. When women were navigating the process of breastfeeding, they realised that they were not prepared for breastfeeding due to their unrealistic expectations. All the women in this study assumed they would breastfeed their baby and they did not expect to face difficulties. When the women started breastfeeding, they recognised the mismatch between the reality of breastfeeding and their expectations and were surprised by the difficulties they encountered. For example, they realised that breastfeeding was not as easy a task as they had assumed; thus, they felt upset and disappointed. This result is consistent with many studies in which women reported feeling upset when their expectations did not match the reality of breastfeeding, and many of them stopped breastfeeding (Hoddinott and Pill, 1999; Anderson et al., 2018; Edwards et al., 2018). The mismatch between the reality of breastfeeding and previous expectations caused the women in this study to feel uncertain about their ability to breastfeed and whether they would adjust to breastfeeding. This kind of mismatch is also evident in a study by Staneva

219 and Wittkowski (2013), who found that unrealistic expectations about motherhood were linked to women’s difficult adjustment during the postnatal period. The mismatch between the reality and women’s expectations can cause a reality shock, and women feeling inadequate and having low self-esteem (Guyer et al., 2012; Staneva and Wittkowski, 2013; Yang et al., 2019). In this study, many women felt surprised and confused about the nature of breastfeeding; they also felt frustrated because they did not know how to deal with their breastfeeding challenges. As a result, the women were uncertain about their ability to breastfeed.

Despite the women’s feeling of frustration, they did not stop breastfeeding during the early stages because they obtained support from their family. However, family support did not extend for more than six weeks after the birth, which surprised the primigravid women in this study. Following the six weeks after giving birth, primigravid women were navigating the reality of their family support for breastfeeding, which was limited. Primigravid women did not expect family members to be unsupportive after six weeks. When six weeks had passed and it was time for the women to return to their homes, they were expected to continue on their own, but they felt anxious because they had not learned how to breastfeed. The women did not learn from their mother about breastfeeding difficulties and their management because they relied on their mother for everything related to breastfeeding. When women moved in with their mothers, they adopted a mother-child relationship, which resulted in the women being disempowered, and they were obedient and compliant regarding their mother. Their mother (the child’s grandmother) presumed her daughter was learning how to breastfeed, but this was not the case. Thus, the women felt worried, as they did not know how to deal with their difficulties with breastfeeding alone. The women could not go back and ask their mother because they knew that their mother had done her best to support them during the first six weeks. The women felt shy about asking for additional support from their mother. Thus, the unknowns remained and the women were uncertain about their ability to continue breastfeeding.

For the multigravida women, they relied on their previous breastfeeding experience and expected to breastfeed. This result is consistent with many studies in which women who had previous breastfeeding experience were anticipating breastfeeding their next baby, rather than as women who had not breastfed before (DaVanzo et al., 1990; Vestermark et al., 1991; Nagy et al., 2001; Huang et al., 2018). However, these women were navigating

220 the reality that their previous breastfeeding experience did not help with their current difficulties with breastfeeding. They realised that for each baby there is a different story and a different experience. During the first six weeks after the birth, women adopted a mother-child relationship, which resulted in the women being disempowered, and they were obedient and compliant when they were with their mother. They did not learn how to deal with and overcome their difficulties because they wanted to take advantage of the six weeks. After six weeks, the women sought support from healthcare professionals, but to no avail. As these women had previous breastfeeding experience, healthcare professionals believed that they knew how to breastfeed and how to manage breastfeeding difficulties; thus, they did not support the women. The women could not ask their mother for support because they felt shy about asking for additional help. Thus, the women felt confused because they did not know how to overcome difficulties with breastfeeding and, as a result, they were uncertain of their ability to breastfeed.

Women were also navigating the reality of the support provided by healthcare professionals within the healthcare institutions. They realised that healthcare professionals ignored breastfeeding support during the antenatal and postnatal periods. It appeared from the excerpts from the women’s interviews that healthcare professionals lacked empathy, did not provide support, even when asked, showed unsupportive and negative behaviour and redirected breastfeeding women to their mother for help. The lack of healthcare professional support might have affected the women’s ability to continue breastfeeding. This result is found in many studies (Pemo et al., 2019; Ranch et al., 2019; Emmott et al., 2020). When the women noticed the negative attitude of the healthcare professionals, they felt that they were a burden to them. Many women in this study reported a lack of healthcare professionals’ support for breastfeeding, which led them to feel that healthcare institutions were not a suitable place to obtain breastfeeding support. As a result, the women avoided asking about breastfeeding during their follow-up appointments. The women did not know what to do to address breastfeeding challenges or where to go for help and remained within a whirlpool of uncertainty. The women thought that they were incapable of breastfeeding and felt confused and undermined.

Navigating the unknowns while experiencing feelings of uncertainty about how to deal with breastfeeding difficulties made the women’s breastfeeding journey difficult when they did not receive support. The majority of the women experienced difficulties with breastfeeding. Breastfeeding was a difficult task that came immediately after childbirth.

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Thus, the women felt confused and did not know what to do with their challenges with breastfeeding, especially when there was a lack of support from family members and healthcare professionals after six weeks following the birth. These findings are consistent with many studies in which women mentioned that lack of knowledge affected their ability to continue breastfeeding (Sriraman and Kellams, 2016; Wallenborn et al., 2017; Hamze et al., 2019). The women in this study felt uncertain about their ability to continue breastfeeding and so they stopped breastfeeding. Many studies reported that lack of knowledge about breastfeeding and how to manage the issues associated with it, as well as poor breastfeeding support, were key reasons for women stopping breastfeeding (Smith et al., 2012; Mehwish et al., 2017; Irby et al., 2019). The women in this study stopped breastfeeding due to physical pain, having to return to work and their perceptions of insufficient milk production.

In summary, the core category, ‘Navigating the Reality of Breastfeeding’, developed from three main categories: Breastfeeding Expectations, Breastfeeding Support and Breastfeeding Journey. The three main categories reflected the experiences of breastfeeding women and the perspectives of the women’s family members and healthcare professionals with regard to breastfeeding in Oman. From the women’s interviews, it appeared that they did not know the reality of breastfeeding before childbirth. The women realised the reality of breastfeeding after they started breastfeeding. Thus, when the women faced difficulties with breastfeeding, they did not know how to deal with them and, therefore, their breastfeeding experiences were difficult. From the perspectives of the participants, it appeared there was a need to develop a health education programme to inform women about what to expect while breastfeeding.

Navigating various unknowns with feelings of uncertainty made the women’s experience of breastfeeding difficult. As a result, the majority of the women in this study stopped breastfeeding. Only three women were able to breastfeed their baby despite the difficulties up to the end of the data collection process (four months). These three women were in similar circumstances to those of the women who stopped breastfeeding but were able to continue breastfeeding. This led to the emergent theory: ‘Resilience: The Power to Breastfeed’. The theory was generated from these findings and is discussed in section 8.5.

In the following sections, the findings of this study are synthesised under two main headings: breastfeeding intention and women’s ability to breastfeed. The central issues

222 that were identified are connected with the existing theories, compared with the literature and discussed.

8.3 Breastfeeding Intention

Within the Omani context, knowledge about and the practice of breastfeeding are transferred from one generation to the next. The women in this study constructed their beliefs regarding breastfeeding from their social interactions within their close and broader communities. For many women, their mother (the child’s grandmother) was the primary reference for learning how to breastfeed. For the women in this study, their intention to breastfeed was constructed socially. Thus, they believed in their ability to breastfeed. This section is presented under two sub-headings: the sociocultural construct of the intention to breastfeed and women being expected to breastfeed.

8.3.1 Sociocultural construct of the intention to breastfeed

Women in this study did not make any conscious decision to breastfeed; rather, before childbirth, all the participants had intended to breastfeed their baby. For example, the women did not have a plan for breastfeeding and how they could overcome any difficulties that might arise. The women’s intention to breastfeed was constructed socially within the Omani context through a process of socialisation. Women’s intention to breastfeed was constructed from three aspects: the social context, religious instruction and family influences. These aspects are discussed below in more detail.

Social context of breastfeeding intention

The participants had intended to breastfeed because breastfeeding is the usual practice among the women of Oman. The women also considered breastfeeding as part of their responsibility of being a mother and a good mother. Breastfeeding means that mothers show care for and kindness towards their baby; thus, breastfeeding is defined as belonging to women’s duties. This concept is emphasised by Hjälmhult and Lomborg (2012), who referred in their empirical studies to the principal role that breastfeeding plays in women’s experiences and how it is connected with motherhood. Women considered themselves to be mothers when they were breastfeeding (Hjälmhult and Lomborg, 2012; Martucci, 2015; Van Esterik, 2018). The women in this study were expected to show skill in fulfilling their responsibility; consequently, failing to demonstrate skills within their role

223 meant failing in the responsibilities of motherhood. Omani women are brought up with these two beliefs since childhood, and they see other women within their community who are breastfeeding. The women in this study constructed their intention to breastfeed because they understood that they would behave like other women within their community and breastfeed their baby. They had conformed to social norms because it is unusual to see Omani women argue or refuse to breastfeed. In the literature, studies have discussed the sociocultural construction of breastfeeding as having a fundamental influence on women (Phoenix et al., 1991; Mäher, 1992; McBride-Henry et al., 2009; Williamson et al., 2011; Powell et al., 2014; Spencer et al., 2015; Van Esterik, 2018). Women maintain their status as a good mother in society by conforming to breastfeeding expectations within their community (Spencer et al., 2014; Valizadeh et al., 2016). There was no flexibility for the women in this study to say no to breastfeeding because they had no choice. Women had to breastfeed their baby as a result of the social influences within the Omani context. The women believed that if they chose not to breastfeed, they would not be a good mother. This idea is found in a study by Knaak (2010), in which women did not consider any option other than breastfeeding because of social expectations. However, it is essential to mention that one of the eligibility criteria for this study was to include women who were exclusively breastfeeding their baby. Thus, women who had chosen not to breastfeed were not included in this study because they did not meet the inclusion criteria.

Religious construct of breastfeeding intention

Women in this study built their intention to breastfeed upon Islamic instruction and guidelines for breastfeeding. The women were influenced by the teachings of the Prophet Muhammad’s (Peace Be Upon Him) wives on breastfeeding and their encouragement to women to breastfeed. Thus, older women (grandmothers) taught and encouraged their daughters to breastfeed. Haider et al. (2010) interviewed Muslim women who wanted to breastfeed for two years in order to obey the instruction in the Holy Quran, which stipulates that

the mothers shall give suck to their children for two whole years, that is for those parents who desire to complete the term of suckling….and if you decide on a foster suckling-mother, there is no sin on you, provided you pay the mother what you agreed on a reasonable basis (Surat Al-Baqarah, 2:233).

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Most of the Omani women in this study intended to breastfeed their baby until the age of two years to gain Allah’s reward for following the Holy Quran. The women in this study also knew that in Islam it is not compulsory to breastfeed for two years if the woman cannot do so. Breastfeeding in Islam is optional for women and not mandatory under certain conditions, such as the woman being ill, the woman’s death, and divorce. Omani women cannot say they would not breastfeed when they were encountering difficulties with breastfeeding because, under Islam, these are not conditions in which they are allowed to stop.

Family influences on women’s intention to breastfeed

Women also intended to breastfeed because of their family’s encouragement during pregnancy. Many of the women in this study identified family members, especially their mother, mother-in-law or husband, as having encouraged them before the birth to breastfeed, and thus they intended to breastfeed. A study by Lok et al. (2017) identified and explained a strong relationship between family members’ encouragement and support for breastfeeding and a woman’s intention to breastfeed. In this study, older family members also taught the women, during pregnancy, of the benefits of breastfeeding. Women in this study were trying to conform to their mother’s instructions with regard to the health benefits of breastfeeding. Thus, they intended to breastfeed because they did not want to deny their baby or themselves the advantages of breastfeeding. The women considered breast milk to be the best source of food for their baby, and thus they intended to breastfeed. Several studies have shown that many women want to breastfeed due to the advantages of doing so for their baby and themselves (Moore and Coty, 2006; Hawley et al., 2015; Obeng et al., 2015; Binns et al., 2016; Holcomb, 2017). Women intend to breastfeed their baby because they know that breast milk provides nutrition, vitamins and improved immunity for their baby (Nabulsi, 2011; Hawley et al., 2015; Obeng et al., 2015). Other women intend to breastfeed due to the benefits of breastfeeding for themselves, such as losing weight and uterine involution (Nabulsi, 2011; Obeng et al., 2015). Racine et al. (2009) found that women breastfed for a long time because of their personal beliefs about the health benefits of breastfeeding and strong emotions towards the practice. However, other studies have indicated that women’s intention or desire to breastfeed their baby does not necessarily lead to successful breastfeeding (Sheehan et al., 2006; Williamson et al., 2013; Spencer et al., 2014). That result is also found in this study, as although all the women intended to breastfeed their baby, most of them stopped 225 breastfeeding before the time they had intended. Many of the women intended to breastfeed for more than six months; however, they stopped breastfeeding before they had originally intended to do so.

As mentioned above, the women in this study constructed their intention to breastfeed from three aspects: social, religious and family. Thus, women in this research study felt that they would be able to breastfeed.

8.3.2 Being expected to breastfeed

Women who participated in this study had expected, before the birth, to breastfeed because they considered breastfeeding to be a natural process and other women thought that they could rely on their previous breastfeeding experience.

Considering breastfeeding as a natural process

One of the messages the women received from their mother was to regard breastfeeding as a natural process. This notion was constructed through socialisation and thus the women assumed that they would be able to breastfeed. Before childbirth, the women participants presumed that breastfeeding would be an easy mothering role for them and their baby. This reflects the findings of a number of other studies (Mozingo et al., 2000; Hauck et al., 2002; Shakespeare et al., 2004; Ryan et al., 2011; Sheehan et al., 2013; Stuart-Macadam, 2017), in which women presumed that breastfeeding would come naturally to them and their baby. After breastfeeding initiation, it was clear in this study, however, that the reality was not in accordance with the women’s expectations, which led to their feeling uncertain about their ability to breastfeed. Thus, it could be seen that the women in this study were trying to conform to their mother’s instructions with regard to breastfeeding and were attempting to breastfeed in spite of the difficulties they encountered. This result confirms the finding of Williamson et al. (2011), who identified that there was a tension between women trying to breastfeed their baby and the cultural construction of breastfeeding as natural. The mismatch between the reality of breastfeeding and women’s expectations caused women to feel confused and thus uncertain about their ability to breastfeed.

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Previous breastfeeding experience

Another message constructed within the Omani context was to consider multigravida women as experts who knew about breastfeeding because they were armed with previous experience of it. In this study, multigravida women believed in their ability to breastfeed because they relied on their past breastfeeding experience. The women believed in their ability to breastfeed because they felt that they knew how to do it, and thus they would be successful in their next breastfeeding. Many of the studies reviewed for this research found that women who had breastfed their previous baby were more likely to breastfeed their next one than women who had not previously breastfed (DaVanzo et al., 1990; Vestermark et al., 1991; Nagy et al., 2001; Huang et al., 2018). In this study, healthcare professionals also considered multigravida women as experts who knew about breastfeeding, and so did not support them. However, multigravida women did not know everything about breastfeeding; they only knew their own experience with it. Once women started breastfeeding, they recognised that the reality was different from their expectations and they faced new breastfeeding challenges that some could not manage. Women who had breastfeeding experience thought that they could better deal with potential problems. After the birth, however, the women remarked that previous experience did not help them overcome their current breastfeeding difficulties. They stated that for every baby, there was a new story and a new struggle. Two qualitative studies have explained that breastfeeding difficulties are common and personal experiences among women and breastfeeding difficulties could vary from one baby to another for the same woman (Mozingo et al., 2000; Nelson, 2006).

Social practices of breastfeeding within the Omani context were seen in this study to have affected women’s behaviour. Sociocultural factors were the most influential, and those that affected women’s ability to breastfeed are discussed in the following section.

8.4 Women’s Ability to Breastfeed

In this study, all the women had initiated breastfeeding and continued breastfeeding up to at least eight weeks after giving birth. The majority of the women had stopped breastfeeding at different intervals during the first four months. Only three women continued breastfeeding up to the end of the data collection period. They did this by using adaptive or problem-solving strategies, such as rescheduling their own sleeping time,

227 asking questions of breastfeeding experts in their family, searching on the internet for additional information about their issues with breastfeeding and receiving support from family members or a housemaid. From the three main categories (Breastfeeding Expectations, Breastfeeding Support and Breastfeeding Journey), it was identified that the system and structure within the Omani context lacked preparing women for the practical and theoretical components of breastfeeding, which ultimately affected their ability to breastfeed, which appeared in different forms: (i) a mismatch between the reality of breastfeeding and women’s expectations; (ii) lack of social support for breastfeeding; (iii) lacking the practical component of breastfeeding; and (iv) lack of knowledge of breastfeeding difficulties and their management. The impacts of these factors on women’s ability to breastfeed are discussed in the following sub-sections.

8.4.1 Mismatch between the reality of breastfeeding and women’s expectations Women in this study had unrealistic expectations with regard to breastfeeding. Before childbirth, the women expected breastfeeding to be an easy task and without difficulties. When women started breastfeeding, they recognised that they had unrealistic expectations. Women were surprised by difficulties with breastfeeding; thus, they felt upset and disappointed. At the early stage of breastfeeding, women struggled with breastfeeding techniques and experienced physical discomfort such as sore or inverted nipples. The women did not know how to deal with these problems; thus, they felt upset, disappointed and frustrated. Women in this study felt that they lived within a whirlpool of unknowns until they stopped breastfeeding. This result is consistent with many studies in which women felt upset when their expectations did not match the reality of breastfeeding, and many of them stopped breastfeeding (Hoddinott and Pill, 1999; Anderson et al., 2018; Edwards et al., 2018). Women were uncertain about their ability to breastfeed and whether they would adjust to breastfeeding or not. The mismatch between reality and women’s expectations can cause a form of reality shock, causing them to feel inadequate and to have low self-esteem (Guyer et al., 2012; Staneva and Wittkowski, 2013; Yang et al., 2019). In this study, many women felt confused about the nature of breastfeeding; they also felt frustrated and were uncertain about their ability to breastfeed.

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8.4.2 Lack of social support It seems from the study findings that there was a lack of social support for the women who were breastfeeding, which appeared in different forms: lack of continuity of family support after six weeks postnatal; lack of support from healthcare professionals; lack of community support for breastfeeding in public; and lack of breastfeeding support in the workplace. Lack of social support affected women’s ability to breastfeed. The impact of the lack of social support on women’s ability to breastfeed is discussed in the following sub-sections.

Lack of continuity in family support after six weeks postnatal One of the critical findings in this study was the positive influence of grandmothers’ support on women to continue breastfeeding despite difficulties in the early stage of breastfeeding. Breastfeeding worked well for all the women in this study until six weeks after the birth because they had been staying with their mother during those initial weeks (at the grandmother’s house). Grandmothers provided support by teaching the women about practical aspects of breastfeeding (i.e., how to breastfeed), encouraging them to continue breastfeeding, and providing other aspects of care for the women and their baby. The importance of other people in terms of breastfeeding women being able to sustain breastfeeding was consistent with many studies that discussed the provision of practical and emotional support for breastfeeding women, not only from their husband, but also from peers (Dennis et al., 2002; Dykes, 2005; Britton et al., 2007; Spencer et al., 2014; Alianmoghaddam et al., 2017; Kabakian-Khasholian et al., 2019; Putra and Krianto, 2019). These other studies also discussed the importance of the presence of others, especially family members and peers, for breastfeeding women when the women faced difficulties with breastfeeding (Dennis et al., 2002; Dykes, 2005; Britton et al., 2007; Spencer et al., 2014; Kabakian-Khasholian et al., 2019).

After the six-week postnatal period, women returned home and no longer received support from their family. It seems that a lack of family support had an impact on the women’s ability to continue breastfeeding. The women were not able to breastfeed in addition to their other activities because they felt overloaded. This reflects other studies which have found that breastfeeding women needed support to continue breastfeeding and when encountering breastfeeding challenges (Dykes, 2005; Britton et al., 2007; Spencer et al., 2014). In this study, grandmothers provided good support for six weeks after the birth. However, after six weeks, the grandmothers could not continue supporting 229 their daughters. The reason for not providing ongoing support to their daughters was that support up to six weeks was a social practice that they had learned from the previous generation and they were following the same notion. The older family members also wanted the women to depend on themselves for breastfeeding and to be responsible for their own baby and home. This picture was also found in a study by Ussher et al. (2000) conducted in the UK, where the culture presents women as superwomen who can cope with caring for a new baby and completing domestic tasks. Within the Omani context, women are accountable for their children and home and it is believed that they should take full responsibility for their children, without any consideration given to their working conditions. Breastfeeding and doing household chores are routine work for women in Oman, but this does not take into account the working state of women (e.g., having a full- time job). Rashad et al. (2005) argued that the expected role of Arabian women is to take care of their children and home, this expectation being rooted in cultural and religious beliefs. Failing to meet this expectation places Arabian women in an uncomfortable position within their communities (Rashad et al., 2005).

In addition, the women in this study found that their husband’s support was insufficient. The women’s husbands were working in distant areas and their support was limited to the period when they were with their wife (often only during the weekend). Husbands encouraged the women to continue breastfeeding and some took care of other children while the women were breastfeeding or doing domestic work. The importance of the husband’s/partner’s support for breastfeeding is well known (Wahyutri, 2014; Fitri et al., 2017; Putra and Krianto, 2019). The importance of the husband’s presence during breastfeeding was not solely limited to encouraging women to breastfeed, but also to enhance closeness in their relationship and their relationship with the baby. Breastfeeding provides a unique opportunity for parents to establish bonds with their baby (Ekström et al., 2003; Shariat and Abedinia, 2017).

Women need support from family members to help them feel empowered to breastfeed their baby (Locklin, 1995; Hauck et al., 2002). Women in this study felt stressed and overloaded due to undertaking household chores or working full-time and attempting to find time for breastfeeding. The majority of the women did not have the skills to deal with breastfeeding difficulties without family support. They did not know how to deal with or overcome breastfeeding difficulties without their family and thus stopped breastfeeding earlier than they intended. Many studies have discussed the importance of

230 family, husband and friends for breastfeeding women and their role in supporting the women to face breastfeeding difficulties and providing encouragement (Babakhanian et al., 2019; Brown and Trickey, 2019). Some of the women in this study were able to continue breastfeeding by using problem-solving strategies, such as seeking knowledge from their mother after the six weeks following giving birth.

When women moved in with their mothers, they adopted a mother-child relationship, which resulted in the women being disempowered, and they were obedient and compliant regarding their mother. During the first six weeks after the birth, the majority of the women depended on their mother for everything for themselves and their baby. Grandmothers did everything for their daughters, such as taking care of them and their baby and cooking for them. It seems that there is a strong emotional attachment between grandmothers and their daughters. This psychological relationship is evident in the findings, which reported that the women stated that they loved their mother; one grandmother stated: “I have to support my daughter, this is my role”. This idea is rooted in Parent Development Theory (PDT) (Mowder, 2005). In PDT, parents’ roles are divided into two categories: a nurture role and a structure role (Mowder, 2005). In the nurture role, parents take care of their children and provide basic needs, such as food, love and support (Mowder, 2005). Parents accept and admit their children as they are and do not assume a change in their children’s behaviour (Macfie et al., 2015). This role makes children feel happy because they know that their demands will be met (Mowder, 2005). However, when parents provide too much of a nurturing role, they become overprotective and overly involved in their children’s lives, which leads to the children not learning the skills they need to care for themselves (Macfie et al., 2015). In the structure role, parents provide direction, set limits, hold their children responsible for their performance and behaviour, and teach them values (Macfie et al., 2015). Parents assume a change in their children’s behaviour and that their children’s ability to do things increases (Macfie et al., 2015). In this study, women were cared for by their mother for six weeks after childbirth. The grandmothers’ nurturing role was greater and they were involved in everything to help their daughters during breastfeeding; thus, many women relied on their mother and did not learn how to deal with or overcome breastfeeding difficulties. The grandmothers did not use the structure role and the women did not increase their ability to breastfeed. Women adopted a mother-child relationship, which resulted in the women being disempowered, and they were obedient and compliant regarding their mother. However,

231 the mothers (grandmothers) presumed their daughters were learning how to breastfeed, but this was not so. Women did not learn from their mother about how to breastfeed during the first six-week period.

Minuchin (1973) discussed how boundaries determine appropriate family roles and argued the importance of maintaining psychological boundaries within the family, especially between parents and their children, for healthy development. Boundaries are flexible and allow family members to be close to each other but to have a sensation of separation (Minuchin, 1973). When parents cannot maintain boundaries between themselves and their children, it leads to boundary dissolution (Kerig, 2005). Kerig (2005) stated that boundary dissolution occurs when parents are overinvolved, too intrusive, and overprotective of their children (which is usually the case in the Omani culture). Boundary dissolution demonstrates parents’ failure to recognise the psychological separateness of their child (Kerig, 2005). In this study, during the first six weeks after birth, the grandmothers were highly supportive of their daughters (breastfeeding women); however, instead of directing them in how to breastfeed, they did everything possible for their daughters and the baby. This form of support by the grandmothers had an impact on the breastfeeding, as the women relied on their mother during the first six weeks after childbirth and did not learn about breastfeeding. During the literature review, no studies identified the ‘backfiring’ of babies’ grandmothers’ support for breastfeeding women.

Lack of support from healthcare professionals Many women in this study were unhappy with the care given by healthcare professionals because they did not instruct them in how to breastfeed during pregnancy or support them while they were breastfeeding, whether they asked for help or not. This unsupportive behaviour from the healthcare professionals’ side made the women unhappy about the level of care provided with regard to breastfeeding. This form of displeasure among breastfeeding women towards care providers was also found in studies by Bergman et al. (1993), Coreil et al. (1995), Tarkka et al. (1998), Quinn et al. (2019) and Blixt et al. (2019). The negative attitude of healthcare professionals towards breastfeeding indicates that they did not regard breastfeeding as a priority in comparison with the other tasks assigned to them. The reason for the negative attitude of healthcare professionals was that they complied with wider community attitudes. According to the healthcare professionals who took part in this study, support with breastfeeding was the role of grandmothers as

232 part of the social practice within the Omani context, so they did not help women with breastfeeding. This result contradicted the findings of many studies in which midwives acknowledged that one of their primary roles in a healthcare institution is to support women during breastfeeding (Pemo et al., 2019; Rm et al., 2019; Smyth and Hyde, 2020). Many of the healthcare professionals in this study did not agree with helping women during breastfeeding because they believed that breastfeeding support was the grandmothers’ role within the Omani context. The attitude of healthcare professionals towards breastfeeding alienated women from asking for support during the early postnatal period. The women in this study felt upset when healthcare professionals concentrated on completing their routine care without considering their needs as breastfeeding women. Many of the women reported that healthcare professionals were rude to them and they felt offended when caregivers focused on finishing their tasks without considering their needs (Simmons, 2002; Sword, 2003; Manhire et al., 2007; McInnes and Chambers, 2008; Schmied et al., 2011; Taylor et al., 2019). Thus, the women looked for alternative methods to complement their unmet needs, such as seeking help and support from their mother and mother-in-law in the immediate period after the birth or searching for information on the internet. In contrast, women in other studies felt that healthcare professionals supported them in hospital and after discharge by providing helpful information about breastfeeding and encouragement, which empowered the women to breastfeed their baby (McNatt and Freston, 1992; Mannion et al., 2013; Chaput et al., 2015).

Other factors that contributed to the negative attitude of healthcare professionals towards breastfeeding support within healthcare institutions included a shortage of healthcare professionals, the short stay of women in hospital, no clear job description about breastfeeding support and lack of training about breastfeeding counselling. These factors are explained in detail below.

The healthcare professionals in this study talked about issues associated with the shortage of midwives and nurses in maternity units, which included a heavy workload, inadequate exchange of information, and a lack of breastfeeding support. The effects of staff shortages were identified in a study by Sogukpinar et al. (2007) and Pemo et al. (2019), who found that a shortage of human resources was considered a constraint on providing information and support. Human resource shortages also increased the workload for nurses and midwives (Mathole et al., 2005; Pemo et al., 2019). Therefore, it was seen that

233 shortages of staff within the healthcare institutions selected in this study affected healthcare professionals’ attitude and they prioritised the immediate care they needed to give to the women. Thus, the quality of postnatal care provided to breastfeeding women might be affected.

Furthermore, the short stay of women postnatally affected healthcare professionals’ attitude towards breastfeeding support. According to the healthcare professionals, they were unable to teach women about breastfeeding because of the women’s short stay in hospital, which is approximately 24 hours for a normal birth. Healthcare professionals reported that they did not have enough time to support women when they were breastfeeding. A number of studies identified that women with a short stay in hospital might have inadequate time to receive support in learning breastfeeding techniques (Emery et al., 1990; Winterburn and Fraser, 2000; Heck et al., 2003; Thomson and Crossland, 2013; Pemo et al., 2019). As a result, the healthcare professionals in this study provided support that accorded with the time available to them. Unlike high-income countries, such as the UK, Oman does not have midwives to perform home visits to support breastfeeding women. Before discharge from hospital, the healthcare professionals advised women to follow up their appointments at the second and sixth weeks after childbirth in the health centre nearest to their residence.

There was also a conflict between the role of healthcare professionals in breastfeeding support and their job description, implying that breastfeeding is not required. Therefore, the healthcare professionals considered breastfeeding a low priority when providing care to women in postnatal clinics, which could also have an impact on the care the women received. According to the International Confederation of Midwives (ICM, 2010), one of the midwife’s roles is to provide high-quality antenatal care to promote health during pregnancy by preparing women for breastfeeding (ICM, 2010). Midwives also have to teach women about the indicators of breastfeeding complications, such as sore nipples (ICM, 2010). Unfortunately, the role of the healthcare professionals in this study with regard to breastfeeding was not stated in the breastfeeding policy and job description. Therefore, healthcare professionals did not support women during the antenatal and postnatal periods within the healthcare institutions in Oman. According to two studies on healthcare professionals’ breastfeeding support, when the job description of healthcare professionals does not include breastfeeding support for breastfeeding women, this results in a lack of support for breastfeeding (Rossman et al., 2012; Soti-Ulberg et al., 2020).

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Lack of training was another of the reasons for the negative attitude reported in this study of healthcare professionals towards providing breastfeeding support. Many healthcare providers do not offer breastfeeding counselling because they do not know how to provide professional support for women when they are breastfeeding. Two studies have identified the positive effect of breastfeeding counselling on the duration of breastfeeding, and found that this could increase the length of breastfeeding (Haider et al., 2000; Coutinho et al., 2005; Gupta et al., 2019). Therefore, lack of training in breastfeeding counselling affected the healthcare professionals’ attitude towards breastfeeding support in this study, and thus they did not support women during breastfeeding. Only one healthcare professional had received specialised training on breastfeeding counselling from a neighbouring country before she started working at the study site. According to this healthcare professional, she assessed women and provided support according to the time available and the workload.

The need for breastfeeding counsellors and breastfeeding classes to support breastfeeding women in maternal clinics during the antenatal and postnatal periods was evident in this study. Haider et al. (2000) recommended incorporating breastfeeding counsellors in mother and child health programmes in low- and middle-income countries, as this could be effective in increasing the duration of breastfeeding. It has also been found that breastfeeding classes for pregnant women during the antenatal period helped prepare the women for breastfeeding and motherhood after childbirth (Greenwood and Littlejohn, 2002; Lumbiganon et al., 2012; Fraser et al., 2020). Breastfeeding classes and breastfeeding counsellors are not available in the maternal clinics in the MOH healthcare institutions in Oman. It seems that the lack of healthcare professionals’ support in the selected institutions had affected women emotionally because they did not receive the encouragement and support they needed. For example, when some of the women experienced physical discomfort, they did not find the midwives supportive of them, which led the women to avoid healthcare professionals during the follow-up appointments. The busy workload and lack of human resources within the healthcare institutions led to a lack of communication between the healthcare professionals and the women, which affected their ability to build a relationship and spend time with the women. There is no breastfeeding counselling service available within the selected healthcare institutions. Breastfeeding counselling may allow women and healthcare professionals to establish rapport, which is essential in allowing counsellors to react and

235 respond in a suitable way when women face breastfeeding difficulties during the early days after birth (McFadden et al., 2019).

Lack of community support for breastfeeding in public

Breastfeeding in public was a challenging task for all the women in this study, due to their husbands preventing the women breastfeeding in public and exposing their breasts, which is referred to the Islamic religion, and the lack of availability of private areas in which to breastfeed. Exposing their breasts was an issue among the women who participated in this study. According to Marchand and Morrow (1994) and Sheehan et al. (2019), women preferred artificial feeding when they were outside their home because they felt embarrassed about exposing their breasts in public. Other women in this study breastfed cautiously when their baby needed to breastfeed in public. For instance, women covered their breasts with a scarf and hid in their car while breastfeeding in public. This picture indicates that the women felt shy about exposing their breasts in public. This notion is present in high-income countries and low-income countries. Many women in high- and low- income countries have described breastfeeding in public as embarrassing (Hoddinott and Pill, 1999; Raisler, 2000; Earle, 2002; Carrera and Hilary, 2019). Other women have used strategies to limit the negative impacts, such as by avoiding breastfeeding in public so that they will not be faced with opposing opinions (Hauck and Irurita, 2002; Sheehan et al., 2019).

Islam promotes breastfeeding but it is a sin for Muslim women to expose their body in front of men other than their husband, so they are discreet during breastfeeding in public. Women in this study were concerned about exposing any part of their body in public, as referred to in the Holy Quran: “O Prophet, tell your wives, your daughters, and the wives of the believers that they shall lengthen their garments. Thus, they will be recognized and avoid being insulted. God is Forgiver, Most Merciful” (Surat Al-Ahzab, 33:59). This image was presented in a study by Zahid et al. (2016), which reported that Muslim women were careful while breastfeeding in public due to their worries about exposing their breast. In addition, Omani men do not encourage their wives to breastfeed in public because they are concerned about their wife’s breasts being seen by another male, as this is prohibited in Islam.

There were different views about breastfeeding in front of particular people. For example, some women in this study reported that they breastfed in front of female strangers,

236 whereas others felt worried about breastfeeding in front of women they did not know because of the fear of envy, which refers to when people harm others because of the ‘evil eye’. Some of the women in this study believed that when some women watch breastfeeding women, they feel jealous. Envy begins when somebody desires something, and evil feelings can influence matters when someone repeatedly watches people while feeling jealousy. All the women participants reported that there was no problem with breastfeeding in front of their mother, mother-in-law or healthcare professionals. The women did not feel embarrassed about breastfeeding in front of female relatives and healthcare professionals, especially when they wanted to learn how to breastfeed. This result contradicted the finding of a study by Twamley et al. (2011) conducted among UK- born ethnic minority women, who felt embarrassed about breastfeeding in front of others, especially healthcare providers. Many women in high-income countries have also been reported as feeling anxious about breastfeeding in front of family members (Boyer, 2012; Hinsliff-Smith et al., 2014).

The challenges of breastfeeding in public affected women’s ability to continue breastfeeding. Women in this study explained that they were uncomfortable exposing their breast in public because their husband had forbidden them to do so; the Holy Quran also advises women not to expose their body. There were also no private places for women to breastfeed in public. The women felt tense when they wanted to go out. Some women preferred to stay at home and isolate themselves from social activities. Others used a breast pump and provided their breast milk in a bottle when they were away from the home. Women could not sustain this situation, which, in turn, affected their ability to continue breastfeeding. Lack of support for breastfeeding in public affected women’s ability to continue breastfeeding. This result is aligned with many previous studies (Foss and Blake, 2019; Wagg et al., 2019; Khresheh, 2020).

Lack of breastfeeding support in the workplace

The data indicated that there is no policy for breastfeeding within the workplace in Oman. Working outside the home is one of the factors that affected the breastfeeding experience among the women in this study who had a job. It was clear that returning to work affected the women’s ability to continue breastfeeding. Working women used a breast pump before going to work, but they could not continue pumping milk from their breast because they felt tired. They also felt stressed because they were worried about being late for work

237 in the morning. The working women in this study found it challenging to continue breastfeeding; as a result, they stopped breastfeeding and started their baby on artificial milk. Early cessation of breastfeeding is higher among working mothers and they have a shorter duration of breastfeeding, 6-9 weeks, compared with non-working mothers (Hill et al., 1997; Arlotti et al., 1998; Lewallen et al., 2006; Hornsby et al., 2019). This outcome was evident in the results of this study, as the women who continued breastfeeding were not working.

As mentioned in the background chapter (chapter one), according to Labour law in Oman, working women in Oman are eligible to take fifty days of maternity leave with full salary after childbirth (Al-Jarida Al-Rasmiya, 2003). The majority of women return to work earlier than that after maternity and annual leave. If women want to stay with their baby, they are eligible to take leave without a salary for only one year, after which women have to return to work. There is no breastfeeding policy for working mothers in Oman to support them to continue breastfeeding. In comparison, high-income countries usually have a breastfeeding policy for working mothers. For example, in the UK, the Sex Discrimination Act (1975) states that breastfeeding women can ask for flexible working time during the breastfeeding period (Equality Act, 2010a). Based on health and safety legislation, employers are also required to have available a place for breastfeeding mothers to relax during working hours and to provide facilities for them when they want to express their breast milk (Equality Act, 2010b). Legally, the employer suspends breastfeeding mothers on full pay if the working conditions of breastfeeding mothers are a health risk for them and their baby (Equality Act, 2010b). In 2003, the UK Government signed up to the WHO Global Strategy for Infant and Young Child Feeding. One objective of the strategy is to protect the rights of breastfeeding for working mothers (WHO, 2013). Oman did not sign up to the WHO Global Strategy for Infant and Young Child Feeding. It was evident in this study that the lack of workplaces supportive of breastfeeding had affected working women’s ability to continue breastfeeding. This unsupportive environment affected women’s ability to continue breastfeeding when they returned to work. Many studies have indicated that a workplace that is unsupportive towards breastfeeding has a strong effect on women’s decision to stop breastfeeding (Wright and Schanler, 2001; Ortiz et al., 2004). Other studies have explained that the presence of supportive programmes in the workplace promotes the ability of working women to continue breastfeeding and to work (Dodgson et al., 2004; Fein et al., 2008). It

238 seems that working women in this study could not balance working and breastfeeding because they were exhausted and stressed. This negative feelings affected the women’s ability to continue breastfeeding.

8.4.3 System lacking the practical component of breastfeeding Women in this study did not know an essential aspect of successful breastfeeding: the practical component of breastfeeding (how to breastfeed). Many women (primigravida and multigravida) did not understand the practical component of breastfeeding, such as appropriate breastfeeding positions and techniques. Within the Omani context, breastfeeding is not considered a skill to be learned, but a natural process that will simply happen. This belief is in contradiction of findings from other studies, in which participants indicated that breastfeeding was a learned skill and they emphasised the importance of learning the skills of breastfeeding during pregnancy (Dykes and Williams, 1999; Mozingo et al., 2000; Hauck et al., 2002; Marshall et al., 2007; Cardoso et al., 2017; Blixt et al., 2019). Primigravida women did not learn about breastfeeding and how to breastfeed during pregnancy as they considered breastfeeding a natural process that would just happen. Nor did multigravida women learn to breastfeed, because they relied on previous experience and, therefore, believed in their ability to breastfeed. Many of the women encountered difficulties with breastfeeding techniques during the early stages; however, they continued breastfeeding for up to six weeks due to their family support. Many studies have indicated that women stop breastfeeding in the early stage of breastfeeding due to encountering difficulties with lactation, such as problems with breastfeeding techniques and having pain while breastfeeding (Odom et al., 2013; Prasad et al., 2017; Gianni et al., 2019; Johansson et al., 2019).

Older family members (grandmothers) did not teach their daughters how to breastfeed during pregnancy. Breastfeeding skills were learned after the birth. Women complied with the older family members’ (the women’s mothers) instructions with regard to breastfeeding practices because they played an essential role in supporting them during breastfeeding. Grandmothers were considered wise women from whom all the younger women took their opinions with regard to women’s and children’s healthcare. Within the Omani community, learning breastfeeding skills after childbirth is common practice and is learned from the previous generation. The value of grandmothers in supporting breastfeeding women was not only recognised by the women participants, but also by the healthcare professionals. Healthcare professionals relied on grandmothers to support their

239 daughters when breastfeeding and, as a result, did not help women with breastfeeding. The position of grandmothers indicates their critical role within the Omani community in supporting women during breastfeeding. Grandmothers play a crucial role in breastfeeding success and their positive attitude towards breastfeeding has an impact on the length of breastfeeding (Bootsri and Taneepanichskul, 2017; Gharaei et al., 2019; Angelo et al., 2020).

Women in this study did not know the practical components needed to breastfeed (how to breastfeed) because the system (socially, healthcare system) within the Omani context did not prepare them for breastfeeding during pregnancy. Many of the women, whether they were primigravida or multigravida, did not know breastfeeding techniques and positioning. They experienced difficulties with breastfeeding immediately after birth. However, the women had breastfed when their mother taught them breastfeeding techniques during the first six weeks. If women learned breastfeeding techniques and positioning when they were with their mother, they might be better able to breastfeed their babies. It appeared that women who had the ability to learn quickly, used their difficult experiences with breastfeeding and learned from them were more likely to succeed in breastfeeding. Learning breastfeeding skills and acquiring knowledge about breastfeeding enhance women’s ability to breastfeed (Shirima et al., 2001). Whereas, women who did not have the ability to learn quickly and to use their difficult breastfeeding experiences by learning from them stopped breastfeeding.

The findings chapters of this study presented evidence that women’s ability to breastfeed was dependent on their being able to adapt to breastfeeding. Only three women continued breastfeeding and they were able to cope with breastfeeding through the use of adaptive or problem-solving strategies, such as posing questions about their issues with breastfeeding to experts in their family, especially their mother. A study by Kabakian- Khasholian et al. (2019) explored how problem-solving ability, such as seeking knowledge and support, assisted women in continuing breastfeeding. Other women adapted to breastfeeding via adaptive strategies, such as rescheduling their sleeping time. The women who continued breastfeeding were good problem solvers and learned from their experience, which, in turn, enhanced their ability to breastfeed.

Lack of ability to solve problems or manage difficulties with breastfeeding were considered to be factors that affected women’s ability to breastfeed. Women’s ability to

240 breastfeed was affected when they experienced a problem while breastfeeding. For example, women who suffered from sore nipples did not know the reason for this issue and the effect of incorrect breastfeeding positioning. Thus, they could not solve this issue and they stopped breastfeeding.

8.4.4 Lack of knowledge of managing breastfeeding difficulties Women in this study did not receive information about common breastfeeding challenges, either before or after the birth, which, in turn, affected their ability to breastfeed and thus they stopped breastfeeding. Providing women before childbirth with adequate information about common breastfeeding obstacles may help them to respond to, cope with and overcome breastfeeding challenges after the birth. This type of information is recommended by Ahluwalia et al. (2005) in her study. She emphasised the importance of providing women with adequate information about breastfeeding obstacles before as well as after childbirth to help them to continue breastfeeding (Shirima et al., 2001; Ahluwalia et al., 2005). It was also found that prenatal and postnatal programmes can help women to deal with issues associated with breastfeeding (Ahluwalia et al., 2005). This assumption is in line with the majority of research studies (Bryant et al., 1992; Scott and Binns, 1999; Sikorski et al., 2003; Taylor and Hutchings, 2012; Dhaliwal and Varghese, 2019). In Oman, healthcare institutions lack antenatal and postnatal programmes about breastfeeding challenges and their management. Providing classes about breastfeeding challenges and how to manage them could enhance women’s ability to breastfeed. It appeared that the lack of supportive structures and systems for breastfeeding within the Omani context had impacted on women’s ability to breastfeed.

The following sub-sections discuss two breastfeeding challenges the women in this study had experienced and they did not know how to deal with them: physical discomfort and perceptions of inadequate milk supply.

Physical discomfort

It was noted that most of the women in this study discussed their early breastfeeding experience as being challenging. Physical discomfort was one of the factors that affected women’s breastfeeding experience. Pain while breastfeeding was the most common physical discomfort reported by the women in this study. The majority of the women participants reported pain while breastfeeding, which led to breastfeeding cessation. This

241 result is aligned with many studies on physical challenges of early breastfeeding that led to breastfeeding cessation (Kelleher, 2006; Jackson et al., 2019; Johansson et al., 2019; Morrison et al., 2019). According to Manhire et al. (2007), women’s physical discomfort after childbirth affected their ability to breastfeed. Other studies also emphasised that sore nipples, trauma or infection can cause early weaning off breastfeeding (Lowe, 1988; Sheehan et al., 2001; Lawrence and Lawrence, 2011; Morrison et al., 2019). Unlike the results of the above studies, women in the current study did not stop breastfeeding at an early stage, in spite of their physical discomfort; they gave up later. The women obtained good support from their family members, especially their mother, and thus continued to breastfeed during the first six weeks postnatal, in spite of the difficulties.

It seems that many women in this study did not expect physical discomfort while breastfeeding. This picture indicates that people within the Omani community promote breastfeeding by highlighting a positive view of it, rather than a negative one. There was secrecy surrounding the difficulties of breastfeeding and grandmothers did not inform their daughters about these difficulties. According to the grandmothers, they suspected their daughters would not breastfeed if they told them about breastfeeding difficulties. During pregnancy, pregnant women’s information needs should be met by providing realistic information about breastfeeding difficulties and ways to overcome them (Dietrich Leurer and Misskey, 2015; Blixt et al., 2019). Presenting only positive aspects of breastfeeding was unrealistic and affected the women’s ability to overcome breastfeeding difficulties.

Perceptions of inadequate milk Women in this study were worried about their babies when they cried for no apparent reason. Their baby’s behaviour led women to doubt they had enough milk and they also doubted their ability to breastfeed. This finding concurs with a systematic review of insufficient milk production (Gatti, 2008). Many women stopped breastfeeding in the first six weeks because they perceived that their milk was inadequate and they were uncertain whether their baby received enough nutrition (Gatti, 2008). Another study (Afiyanti and Juliastuti, 2012) indicated that women believed that their milk was not adequate, which led them to stop breastfeeding before six months. Inadequate milk production is considered to be the most common reason for breastfeeding cessation (Hector et al., 2005; Jessri et al., 2013; Lee et al., 2013; Tarrant et al., 2014; De Roza et al., 2019). In this study, many women were unaware of normal infant behaviour because they had not

242 obtained education about breastfeeding. When their babies cried, the women thought their babies were not receiving enough milk. For example, one woman was worried about her baby’s weight because it was reducing and she thought that her milk was inadequate; she felt, therefore, that she would not be able to continue breastfeeding and provided artificial milk instead. Walker (2002) also found that the perception of inadequate milk production often coincided with a slow gain in the baby’s weight, which led women to stop breastfeeding.

The findings of this study generated the theory ‘Resilience: The Power to Breastfeed’. This emerged theory is discussed in the following section.

8.5 Theoretical Model: Resilience: The Power to Breastfeed

The core category was central to the emergent theory. The core category that emerged, ‘Navigating the Reality of Breastfeeding’, showed that when women moved through the process of breastfeeding, they realised the reality of breastfeeding. This reality was not in accordance with the women’s expectations. Thus, women were uncertain about their ability to breastfeed. Many women stopped breastfeeding because they could not adapt to or manage breastfeeding difficulties. However, three women, who had similar circumstances to the others, were nonetheless able to continue breastfeeding. As a result, the following theory emerged: ‘Resilience: The Power to Breastfeed’. This theory indicates that women’s ability to breastfeed was dependent on their resilience. Resilience is defined as

the capacity for successful adaptation, positive functioning or competence despite high-risk status, chronic stress, or following prolonged or severe trauma (Sonn and Fisher, 1998, p. 458).

Resilience is also defined as “the ability to withstand or successfully cope with difficulty” (Werner and Smith, 2001, p. 83). Applying a resiliency lens to exploring breastfeeding experience affords a chance to understand why only three women in this study continued breastfeeding, whereas the majority of the women (eight) stopped breastfeeding before their planned date. The lens also helped explore factors that enabled women to continue breastfeeding in spite of the difficulties they had and to understand how the women dealt with those difficulties. This theory of resilience helped the researcher to identify the factors affecting the duration of breastfeeding. The theory also helped the researcher to ascertain how adaptive and problem-solving strategies enabled three of the women to

243 continue breastfeeding. Applying a resiliency lens also affords a chance to understand how others, such as family members and healthcare professionals, can play an essential role in women's resilience.

Resilience theory discusses the influence of stressful events on people and how well individuals adjust to those difficult experiences. Anthony (1974) studied children who were resilient to stressful life conditions and discovered that some children did well in spite of the difficulties they encountered. As the research in this field developed, it was found that people have different levels of resilience (Rutter, 1993; Luthar et al., 2000; Tusaie and Patterson, 2006). Resilience includes the interaction between difficulties and people’s internal and external protective factors that allow them to overcome challenges (Rutter, 1985). According to Wagnild and Young (1990), resilient people have a healthy feeling of self-belief and are determined and self-efficacious. Garmezy (1991) identified protective factors that helped people in developing resilience. Internal factors include intelligence, a sense of fun, and the locus of control (Garmezy, 1991). Garmezy (1991) also identified external factors, such as family relationships and support, which help people to be resilient.

The presence of one or more protective factors can decrease the influences of adversity (Rutter, 1985; Resnick, 2000). This means that the greater the number of protective factors, the more resilient people will be. The findings chapters showed that three women were able to continue breastfeeding, and that they had adapted to breastfeeding difficulties by using adaptive and problem-solving strategies. Those strategies, which were employed during the first six weeks after childbirth, helped the women to adapt to breastfeeding difficulties. The strategies included rescheduling the mother’s sleeping time, asking questions of breastfeeding experts in their family, especially their mother, and searching on the internet for additional information about their issues with breastfeeding.

Resilience can also be enhanced through learning (knowledge or skills) (Zimmerman, 2013; Lundberg and Rankin, 2014). A study by Mavhura et al. (2013) highlighted the possible contributions of learning in developing resilient societies. In his book Stories about Teaching, Learning and Resilience: No Need to be an Island, Piscitelli (2017) discusses how learning about situations allows people to develop resilience in facing difficulties and makes them stronger. Learning from breastfeeding difficulties might help women to be resilient, and to cope with and overcome breastfeeding difficulties. Women

244 in this study who succeeded in breastfeeding had the ability to learn quickly, to use their difficulties and to learn from them, which made them better able to cope with breastfeeding difficulties and be stronger in the face of difficulty. Women who learn from situations and experiences could solve their problems with breastfeeding, which, in turn, made them more resilient. However, the majority of the women in this study did not learn from their experience, and they could not solve their breastfeeding problems, which, in turn, reduced their resilience. As a result, the women stopped breastfeeding.

Having support from family members and the presence of other supportive factors, such as having a housemaid, all helped the women to continue breastfeeding. This support enhanced the women’s resilience. For example, a housemaid is responsible for domestic activities; as a result, the women did not feel stressed when breastfeeding at night. The women were able to sleep during the day, not think about domestic tasks and were able to breastfeed at night. This support helped the women to be resilient in the face of breastfeeding difficulties; thus, they continued breastfeeding. A study by Southwick et al. (2005) explained that support could enhance resilience and decrease stress disorder. Support had a positive impact on women persisting with breastfeeding when they encountered breastfeeding difficulties (Trado and Hughes, 1996). However, this was not the case in this study, as the women received extensive support from their mother during the first six weeks after the birth. This support caused the majority of women to depend on their mother and they did not learn about breastfeeding (see section 8.4.2.1). However, the women who continued breastfeeding did not rely too much on their mother and they had taken the opportunity to learn about breastfeeding during this period, which, in turn, made them more resilient when facing breastfeeding difficulties after the first six weeks. The data also revealed that women who continued breastfeeding believed in their ability to breastfeed as breastfeeding became more comfortable with time. According to many studies, persistence and resilience are required from mothers to control and overcome breastfeeding difficulties (Hoddinott and Pill, 1999; Manhire et al., 2007).

People with a positive belief in their ability and efficacy will make an effort to succeed, and they are more likely to continue in the face of difficulty (Bandura, 2010). Self- efficacy can play a large part in women’s resilience, which, in turn, affects their ability to breastfeed. Albert Bandura, the founder of the self-efficacy concept, defined self-efficacy as a perception or personal judgement of “how well one can execute courses of action required to deal with prospective situations” (Bandura, 1982, p. 126). According to

245 resilience researchers, self-efficacy is considered to be a factor or determinant of resilience (Garmezy, 1991; Noble and McGrath, 2005; Gillespie et al., 2007). Self- efficacy is an attribute of several levels of resilience (Werner and Smith, 1992; Rutter, 1993; Masten, 1994; Noble and McGrath, 2005). For example, it has been found that people who enjoy self-efficacy have a high level of resilience in the face of difficulties or adverse events (Bachay and Cingel, 1999; Luszczynska et al., 2005). In this study, women who were self-efficacious were resilient in the face of breastfeeding difficulties, and thus were able to continue breastfeeding. Adaptive and problem-solving strategies, learning quickly and learning from difficulties and experiences were the key for these women, which, in turn, made them resilient in the face of breastfeeding difficulties.

In contrast, women who did not enjoy self-efficacy were less resilient in the face of breastfeeding difficulties and stopped breastfeeding. These women did not use adaptive or problem-solving strategies, did not learn quickly, and did not learn from their challenges and experiences, which led to their being less resilient in the face of breastfeeding difficulties. Self-efficacy is central to the way people look at themselves and their resultant behaviour (Bandura, 1991). Self-efficacy helps people to adopt and sustain particular behaviours (Bandura, 1977). According to Bandura (1977), people measure the outcomes of their behaviours and tend to know the extent to which they can do certain activities. People need to think about the difficulty of the job at hand; the amount of effort required to do the job; the external support they receive; and the conditions in which they do the job (Bandura, 1977). Bandura (1982) suggested that people’s willingness to undertake a task is dependent on their perception of their coping capabilities and they tend to avoid activities that they perceive as being above the level of their ability to cope. The women in this study did not receive antenatal education on breastfeeding skills and challenges and did not know how to manage their difficulties with breastfeeding. Thus, before childbirth, the women did not think about how to overcome breastfeeding challenges or how they would cope with difficulties.

Women who continued breastfeeding also had a desire to breastfeed, were optimistic and possessed a willingness to search for information about breastfeeding difficulties from different sources. They also had support. These factors helped the women to be resilient. Many factors are connected with individuals’ resilience (Southwick et al., 2005) and include optimism and positive emotions, the capacity to adapt to challenges, and determination and courage in relation to an essential purpose (Southwick et al., 2005;

246

Southwick and Charney, 2012). Johnson and Wiechelt (2004) clarified that resilience helps individuals sustain health and hope, despite difficulties. Individuals show resilience when they have inner strengths, abilities, and support to prevent adversity from having a severe impact on their lives (Johnson and Wiechelt, 2004). Another study indicated that thinking positively about breastfeeding problems and how to solve them helped the women participants to continue breastfeeding (Dennis, 2002). In contrast, women who focused on negative aspects of breastfeeding, such as physical discomfort and inconvenience, were not able to continue breastfeeding (Dennis, 2002).

Although they experienced difficulties, the women in this study tried to continue breastfeeding to alleviate social pressure and avoid negative judgements if they were to choose not to breastfeed. This result is reflected in a study by Lupton (2013), in which women wanted to breastfeed to avoid feeling guilty for not conforming to social expectations. Women in the current study tried their best to present themselves as a good mother by trying to continue to breastfeed their baby. This image has been emphasised in many studies, in which women explained that breastfeeding had value in the lives of women and the importance attached to breastfeeding was synonymous with being a good mother (Schmied and Barclay, 1999; Marshall et al., 2007; Loof-Johanson et al., 2013; Williamson et al., 2013; Campbell and Hart, 2019). Within the Omani context, breastfeeding has value in women’s lives and is considered their job or duty. Breastfeeding is also related to women’s identity as a good mother (Campbell and Hart, 2019), and thus the women in this study were trying to continue breastfeeding even though they experienced difficulties. The women felt pressure in their attempts to conform to social expectations and what they called their duty when they found a lack of social support, were unable to manage breastfeeding difficulties and could not continue breastfeeding. At the same time, women were worried about social expectations. Therefore, in order to stop breastfeeding, women knew that they had to find good reasons or excuses to do so (Moffat, 2002; Cwikel and Amir, 2005; Wagner et al., 2013; DeMaria et al., 2020). Women who could not find solutions to their breastfeeding difficulties were less resilient, and once they found what they perceived to be a valid reason or excuse, they ceased breastfeeding. From the women participants’ statements, returning to work, insufficient milk production, a decrease in their baby’s weight and the health condition of their breasts were good reasons or excuses to stop breastfeeding. In contrast, three women were able to solve their breastfeeding difficulties which in turn made them

247 resilient; therefore, they continued breastfeeding. These three women were able to adapt to breastfeeding difficulties and breastfed until the end of the data collection period (four months). In short, women who could not solve their problems with breastfeeding did not continue breastfeeding because they were not able to adapt to breastfeeding difficulties. Whereas, women who used adaptive and problem-solving strategies, learned quickly, identified solutions and learned from them, could continue breastfeeding because they adapted with breastfeeding difficulties. Figure 8.2 illustrates the emergent theory: ‘Resilience: The Power to Breastfeed’.

248

‘Resilience: The Power to

Breastfeed.’

Women’s ability to breastfeed

was dependent on their resilience.

Women were uncertain about their ability to breastfeed.

Mismatch between the reality of breastfeeding and women’s expectations.

‘Navigating the Reality of Breastfeeding’

Breastfeeding Breastfeeding Breastfeeding Expectations Support Journey

Figure 8.2: The emergent theory

8.6 Conclusion

In Oman, previously published research on exclusive breastfeeding has included a quantitative study that examined the prevalence and duration of breastfeeding in one area of Oman. There are no qualitative studies of women’s experience of exclusive breastfeeding in GCC countries, and especially in Oman. The analysis of the findings of this study contribute to knowledge that provides a better understanding of exclusive breastfeeding within the Omani context. This study offers a comprehensive understanding of exclusive breastfeeding from different perspectives, such as those of breastfeeding women, their family members and healthcare professionals. It also provides greater understanding of the barriers to and facilitators of exclusive breastfeeding among Omani women. The findings of this study show that women’s intention to breastfeed was constructed from Omani sociocultural norms and practices. These practices of

249 breastfeeding need to be examined in detail in a future study. It was evident from the data collected in this study that breastfeeding women felt that they were responsible for breastfeeding because they connected breastfeeding with motherhood. The women felt obliged to breastfeed their babies to give them the best food possible and to conform to social expectations with regard to breastfeeding. Before childbirth, women thought that they were ready to breastfeed based on information given to them by family members and seeing other women doing it. The women did not consider breastfeeding to be a skill that should be learned due to their perception that breastfeeding is a natural process and other women relied on their previous experience.

While women moved through the breastfeeding process, they discovered the reality of breastfeeding, which did not accord with their expectations. It appeared from the data that women’s ability to breastfeed was dependent on their being able to adapt to breastfeeding difficulties. Women’s ability to breastfeed was affected because the health care system and structure within the Omani context lacked preparing women for the practical and theoretical components during the antenatal and postnatal periods as well as supporting women during breastfeeding. Women’s ability to breastfeed depended on their resilience. Women were not able to continue breastfeeding when they faced difficulties because they did not know how to manage these difficulties. The women did not use adaptive and problem-solving strategies; they did not learn quickly; they did not learn from difficulties and experiences; and they were not self-efficacious. As a result, these women (n=8) stopped breastfeeding during different intervals of the first four months after childbirth. Whereas, only three women could breastfeed their baby because they used adaptive and problem-solving strategies, they learned quickly, learned from difficulties and experiences, and they were self-efficacious. These women continued breastfeeding until the end of the data collection period, which lasted four months.

Conclusions drawn from this study, the rigour of the research and its reflexivity are discussed in the next and final chapter, together with the strengths and limitations of this research study. Recommendations for practice, policy, education and future research are also suggested in the next chapter. It is intended that these findings will help develop a breastfeeding programme to support breastfeeding women in Oman.

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Chapter Nine: Conclusions and Recommendations

251 Conclusions and Recommendations

9.1 Overview

This research study has explored the experiences of breastfeeding women in relation to exclusive breastfeeding within the Omani context. It has also examined the perspectives of family members of the participants and healthcare professionals on breastfeeding, including the support they provide to the women during the breastfeeding period. This chapter presents the conclusions drawn from this study and highlights the rigour of the research and the reflexivity shown. The strengths and limitations of the research study are also outlined, along with recommendations for practice, policy, education and future research.

9.2 Conclusion of the Study

Research previously published in Oman on exclusive breastfeeding has included quantitative studies that focused on the time at which women stopped breastfeeding and their reasons for stopping. There are limited numbers of qualitative studies on women’s experience of exclusive breastfeeding in GCC countries in general, and particularly in Oman. The analysis of the findings of this study will contribute to knowledge and provide a better understanding of EBF within the Omani context. This study offers a comprehensive understanding of EBF from different perspectives, such as those of breastfeeding women, their family members and healthcare professionals. It also provides greater understanding of the barriers to and facilitators of EBF among Omani women. The findings of this study show that women’s intention to breastfeed was constructed from Omani sociocultural norms and practices. Those norms and practices of breastfeeding need to be examined in detail in future study. It was evident from the data gathered during this research that breastfeeding women felt they were responsible for breastfeeding because they connected breastfeeding with motherhood. The women who participated in the study felt obliged to breastfeed their babies to give them the best food and to conform to social expectations with regard to breastfeeding. Before childbirth, the women thought they were ready to breastfeed based on information given by their family members and from seeing other women doing it. The women did not consider breastfeeding as a skill that should be learned due to their perception that it is a natural process and other women relied on their previous experience.

252 It appeared from the data that women’s ability to breastfeed was dependent on their being able to adapt to breastfeeding difficulties. Women’s resilience in adapting to breastfeeding difficulties was affected by three factors: lacking preparedness for breastfeeding during pregnancy, lack of social support for breastfeeding women after childbirth, and a lack of knowledge of how to manage breastfeeding difficulties. As a result, the women sought alternative methods to clarify their concerns and to find solutions to their issues with breastfeeding. The women’s ability to adapt to breastfeeding difficulties depended on their resilience. In this study, the majority of women (n=8) stopped breastfeeding at various intervals during the first four months after childbirth because they did not know how to manage these difficulties, whereas (n=3) women were able to continue to breastfeed their baby because they used coping or adaptive strategies, despite the difficulties they had. These women continued breastfeeding until the end of the data collection period, which lasted four months. Recommendations for practice, policy, education and future research are suggested below and it is intended that these findings will help develop a breastfeeding programme to support breastfeeding women in Oman.

9.3 Rigour of the Research Study

According to Tong et al. (2007), confirming the quality of a research study is imperative to ensure the study findings can be used to assist decision making and future research. Charmaz’s (2014) criteria of credibility, originality, resonance and usefulness (see Appendix 43) were considered in order to ensure the high quality of the research process of this study. These criteria ensure the usefulness of the research study (Charmaz, 2014), as addressed in the following sub-sections.

9.3.1 Credibility Credibility concerns the richness and accuracy of research data (Beck, 1993). For this study, adequate details have been given of how the data were generated through concurrent data collection and analysis processes (Charmaz, 2014). Credibility deals with the accuracy of the data obtained, the trustworthiness of the study findings (Shenton, 2004) and the authoritativeness of a piece of qualitative research (Johnson and Rasulova, 2016). In addition, credibility is one criterion for assessing how ‘real’ the description of experiences is in qualitative research (Beck, 1993; Ellis, 2018). The thoughtful selection of a grounded theory methodology and methods of data collection and analysis were

253 aligned with the aims and objectives of this study, which is considered the first step towards gaining credibility (Meyrick, 2006; Wahyuni, 2012). For this study, a constructivist grounded theory methodology was used because it is systematic and flexible. The researcher followed the principles of grounded theory to enhance the rigour of the study (Glaser and Strauss, 1967). The methodology involved back-and-forth movements between the data collection and analysis processes, a constant comparative approach, theoretical sampling, and constructing memos (Charmaz, 2006). According to Lazenbatt and Elliott (2005), a constant comparison approach and theoretical sampling give an integrated research approach to data collection and analysis and the assessment of the quality of research findings. The continuous movement between data collection and analysis, a constant comparative method, and theoretical sampling allowed the researcher to produce trustworthy and accurate results in this study. This methodology also allowed a new theory to develop from the data that was denoted as being theoretically complete (Lazenbatt and Elliott, 2005). Constructivist grounded theory was considered a suitable approach because it helped in the examination of behaviours and interactions between breastfeeding women, their family members and healthcare professionals (Goulding, 2005; Huddlestone and Harris, 2006). Using a grounded theory methodology helped engagement in clinical practice by conducting observations. Those observations helped to construct meaningful interpretations of how healthcare professionals supported breastfeeding women in the healthcare institutions selected (Lazenbatt and Elliott, 2005). Moreover, a grounded theory methodology was suitable for this study because of the lack of literature on breastfeeding in Oman and was expected to enable a new theory to be built from the collected data (Birks and Mills, 2015).

The initial analysis of the data from the first samples of breastfeeding women suggested a need to explore the broader context of breastfeeding support to confirm areas highlighted by the interviews. As a result, non-participant observations were conducted at different maternity units. The initial data analysis also suggested interviewing the family members of the same women participants, as well as healthcare professionals. The initial data suggested including additional women in the data collection to understand the exclusive breastfeeding experience (Meyrick, 2006). In this study, credibility was enhanced by gathering rich material from different participants to explore comprehensive data and ensure the representation of various perspectives around exclusive breastfeeding, such as those of breastfeeding women, their family members and healthcare

254 professionals. Data were also collected by utilising different methods, such as interviews and observations. Triangulation was employed to ensure the comprehensiveness of the data, as the researcher compared data collected from different sources and methods (Mays and Pope, 2000). Data for this research study were obtained from different places and various participants with diverse backgrounds; those differences offered variation in the data (Bitsch, 2005). The differences also promoted the credibility of the study by allowing the phenomenon to be viewed from various angles (Bitsch, 2005; Houghton et al., 2013).

The research data for this study have been presented many times in different conferences and showcases in the UK (University of Manchester and Liverpool John Moores University) and in Oman (OmaniExpo exhibition). The feedback and questions obtained from those seminars and conferences were helpful, as they demonstrated resonance with the findings. The presentation of the research findings and the supporting quotations shows a coherent argument that gives a clear explanation of how women understand breastfeeding in Oman.

Furthermore, having regular meetings with the supervisory team during the data collection and analysis stages was beneficial. Close data checks ensured the credibility and confirmability of the research study and were conducted by the study supervisors, who had no connection with either the selected healthcare institutions or the participants.

9.3.2 Originality Originality refers to whether a study has provided novel insights into the events under investigation. It also reflects whether the findings “challenge, extend or refine current ideas, concepts and practices” (Charmaz, 2014, p.337). Many critical novel contributions are recognised in this research study. The grounded theory methodology permitted the researcher to understand the experiences and perspectives of breastfeeding women and the views of their family members and healthcare professionals within the Omani context. This work is the first qualitative study to explore exclusive breastfeeding from different perspectives in Oman. There are only a limited number of studies in Oman about breastfeeding in general and specifically on EBF. Therefore, the findings of this study will provide novel insights from different perspectives and add to the literature available on breastfeeding. According to Charmaz (2014), credibility and originality enhance the resonance and usefulness of a study and the resulting value of its contributions. In this study, the researcher presented a comprehensive explanation of the study context and the

255 sites from which the data were collected. The researcher also provided a detailed account of the emerging categories, core category and theory. According to Graneheim and Lundman (2004), providing detailed explanations of the research study process is essential to enhancing the transferability of a research study. However, the transferability of a research study can also be determined by the people who read it (Graneheim and Lundman, 2004). Readers can judge a research study for themselves and whether the findings are meaningful for them and transferable to their context (Graneheim and Lundman, 2004).

An important finding was that before childbirth, primigravid women did not consider breastfeeding a skill to be learned because they had perceived it as a natural process. Multigravida women did not consider breastfeeding a skill either, because they felt they could rely on their previous experience. During the first six weeks after the birth, all the women in this study received good family support, especially from their mother. The child’s grandmothers also did everything possible to support their daughters during this period. However, the majority of the women did not learn how to breastfeed. During this period, the women relied on their mother when they were breastfeeding. After this period, when women breastfed alone, they were unsuccessful.

The findings revealed that healthcare professionals did not consider breastfeeding support to be part of their role; instead, they emphasised that it was the grandmother’s task. Interestingly, the women participants and healthcare professionals trusted in the credibility of the knowledge and experience of grandmothers, which indicates the valuable role of grandmothers in supporting breastfeeding women within the Omani context. This trusting relationship led women and healthcare professionals to conform to grandmothers’ beliefs and social practice.

The main novel contribution of this study is the research findings that facilitated the emergence of the grounded theory: ‘Resilience: The Power to Breastfeed’. Women’s ability to breastfeed was found to be dependent on their resilience in dealing with or overcoming breastfeeding difficulties. This study provides understanding of the factors that affect women’s resilience in overcoming such difficulties. Women’s resilience was seen to be influenced by a mismatch between the reality of breastfeeding and their expectations, lack of a practical component of breastfeeding, lack of knowledge about breastfeeding challenges and their management, and lack of social support. Women who exhibited self-efficacy were resilient in the face of breastfeeding difficulties and thus were

256 able to continue breastfeeding by using adaptive and problem-solving strategies and learning quickly from difficulties and experiences. In contrast, women who did not enjoy self-efficacy were less resilient in the face of breastfeeding difficulties and stopped breastfeeding.

9.3.3 Resonance Resonance relates to grounded theory making sense of participants’ stories (Charmaz, 2014). The findings of this study were presented clearly from all the participants’ perspectives. The study utilised semi-structured interviews and non-participant observations of various participants, which helped to saturate the property of the emergent theory – ‘Resilience: The Power to Breastfeed’. Saturation was achieved by adding different participants from diverse backgrounds, marital statuses, age ranges, employment statuses and educational levels. Using various methods, the researcher provided a full explanation of and profound insight into perceptions of breastfeeding (Cooney, 2011). Triangulation of the analysis further enhanced the confirmability of the data in this study. The findings were also supported by direct quotations from the participants to emphasise the transparency and truthfulness of the data (Cooney, 2011).

9.3.4 Usefulness Usefulness reflects a study’s contributions to knowledge and indicates how the findings can provide explanations and solutions that can be used in people’s lives (Charmaz, 2014). The data were described in a transparent way and the researcher was clear about the aims and objectives of the study. Previous research describing exclusive breastfeeding published in Oman has involved quantitative studies (Suliman et al., 1992). The present study examined the prevalence and duration of breastfeeding in one area of Oman. Published studies on women’s experience of exclusive breastfeeding in Oman are non- existent. The analysis in this study of the women’s, their family members’ and healthcare professionals’ perspectives contributes to knowledge that provides a better understanding of women’s breastfeeding experience within the Omani context. It also provides a wider understanding of the barriers to and facilitators of exclusive breastfeeding for Omani women. The study also provides a better understanding of women’s resilience in dealing with or overcoming breastfeeding difficulties. The information sought and contained in this study can be used to inform clinical practice, education and policy to promote the experience of Omani women who are breastfeeding exclusively. The knowledge

257 generated can also be utilised to improve breastfeeding support in healthcare institutions, as well as informing future research into exclusive breastfeeding in Oman.

9.4 Reflexivity

According to Corbin and Strauss (2014), earlier hypotheses and viewpoints of researchers might have an impact on a particular research process. Reflexivity helps researchers to recognise preconceptions and motivations and contributes to examining the influence of the researcher on the study settings and participants (Attia and Edge, 2017). Reflexivity is honesty and originality with self, the research and the public (Mosselson, 2010). The most critical aspect of qualitative research is the researcher’s ability to be honest, transparent and responsible towards a correct representation of the participants’ experiences and words in the findings (Simundic, 2013). In this case, the researcher knew the potential influence of her notions or viewpoints on the research process; however, those notions and perspectives were not considered harmful to determining the research problem (Gentles et al., 2014). The researcher’s background as a clinical tutor of nursing students in maternal clinics and as a mother who breastfed her children might have affected the interpretation of the results of this study (Charmaz, 2014). However, this is considered natural when a researcher wants to retain the findings within a field (Corbin and Strauss, 2014). When she was conducting the interviews, the researcher was listening to the participants’ perspectives and showed an interest in what they were saying. The researcher was able to understand the experiences of breastfeeding from the women’s viewpoint as both a woman and a researcher. The researcher also maintained reflective records to limit her influence on the research process.

According to Morse (1994), the background of researchers influences the research process in terms of whether they are insiders or outsiders in relation to the setting of the research. In this study, the researcher regarded herself as an insider researcher because she works under the umbrella of the Ministry of Health in Oman. The researcher is a lecturer at the Oman College of Health Sciences, North Batinah Branch, one of the Ministry of Health’s nursing educational institutions in the Sultanate of Oman. She taught maternal and child health nursing and community health nursing curricula for twelve years. The researcher also has a nursing background and knows about the topic under study. This study was born out of the researcher’s concern for, and to explore the reasons behind, the low breastfeeding rate in Oman. This low breastfeeding rate was detected

258 through her work as a nursing tutor during clinical teaching with nursing students at Maternal and Child Health (MCH) clinics in healthcare institutions in Oman. It was shown from MCH records and MOH statistics that many babies who visited paediatric clinics suffered from diseases which can be prevented through breastfeeding, such as diarrhoea and respiratory tract infections. Many women also stop breastfeeding before six months, which does not align with the recommendations of the WHO. Thus, the researcher was curious to know whether breastfeeding experiences affect breastfeeding rate and duration. The researcher was also interested in learning the reasons behind breastfeeding cessation among breastfeeding women in Oman. The researcher believed that a new viewpoint was needed to understand what it means for women to breastfeed within the Omani context.

The researcher also considered herself an insider because she had breastfed her own children. The researcher breastfed four of her children and experienced difficulties with breastfeeding. The researcher had a high-risk assessment during pregnancy and pregnancy-induced hypertension that continued until after the birth. The researcher breastfed her children until she returned to work. The researcher had thought that she stopped breastfeeding because of her full-time job. However, during her clinical teaching with nursing students in postnatal clinics, she observed that even non-working mothers stopped breastfeeding before the recommended duration. Therefore, the researcher wanted to explore what was happening with regard to women’s experience while breastfeeding and why they did not breastfeed until at least six months after giving birth.

The researcher also regards herself as an insider because she knows healthcare professionals in the study areas, as she had been performing clinical teaching of nursing students in the selected healthcare institutions. However, it is essential to mention that the researcher has not belonged to the healthcare institutions selected. Although the researcher considered herself an insider and knew some of the healthcare professionals concerned, she conducted a meeting with the gatekeepers to introduce herself to them and to familiarise herself with those she did not know. This meeting was useful for the research to tell the gatekeepers about the research study because they would help in gaining access to the study participants (Burns et al., 2012).

Being an insider enabled the researcher to gain fast access to the study area and rapid acceptance by the participants. Being an insider also assisted the researcher in obtaining

259 a greater depth of data (Brannick and Coghlan, 2007) and helped in having her research questions answered with regard to breastfeeding. An outsider researcher may see this acceptance as a source of subjectivity that might affect the research process (Dwyer and Buckle, 2009). However, being an insider researcher was beneficial for this study. A reflexive record of the researcher’s hypotheses was reported during the data collection and analysis processes to inform the influence that the researcher might bring. These reflexive records might be beneficial in lessening the possible problems of being an insider researcher.

The grounded theory methodology has gained special attention from its founder and admits reflexivity (Charmaz, 2006; Charmaz, 2014). The researcher adhered to the direction of constructivist grounded theory as part of an interpretation. Throughout the data collection, the researcher wrote reflections of what went well and participants’ reactions to each interview and observation. However, it was noted that the researcher’s own assumptions could be identified during the process of focused coding and constant comparison and while writing up the study findings (Charmaz, 2014). This methodology helped the researcher to concentrate on the women’s words and experiences of breastfeeding (Attia and Edge, 2017). The use of a grounded theory methodology also helped the researcher to conceptualise the phenomenon under study and to accept subjectivity in order to understand the participants’ words (Charmaz, 2014).

9.5 Strengths and Limitations of the Research Study

The strengths and limitations of this research study are discussed below.

9.5.1 Strengths

A vital strength of this study is its use of triangulation. The researcher obtained data from different sources, which helped increase the trustworthiness of the study (Guion et al., 2011). Data triangulation was maintained in this study by utilising a diverse group of participants, which encompassed breastfeeding women, their family members and healthcare professionals. Triangulation ensures the comprehensiveness of the gathered data (Mays and Pope, 2000). Moreover, different methods were used to collect data, such as interviews and observations. This variety in the data collection increased the chances of answering the research question (Patton, 1980). Another strength of this study is the gathering of data from a wide range of contexts, such as one referral hospital and two

260 health centres across three wilayats in NBG. This variety allowed a sample of extreme variation to be reached (Higginbottom, 2004), which promoted a comprehensive understanding of multiple opinions and viewpoints on exclusive breastfeeding in Oman. In addition, the researcher analysed the data and the supervisory team then assessed a portion of the interviews independently. Triangulation of analysis enhanced the confirmability of the data in this study. Furthermore, a constant comparative approach and theoretical sampling were applied to improve theoretical sensitivity and fulfil the properties of the theory that emerged.

This study was of a longitudinal nature and breastfeeding women were followed up for four months or until they stopped breastfeeding, whichever occurred first. During this period, the women’s experiences of breastfeeding were examined. Following women for prolonged periods was useful to understand the sequence of breastfeeding experiences, to learn the reasons for breastfeeding cessation and its timing and to follow the changes in the women’s behaviour over time (Caruana et al., 2015). Conducting a series of interviews with breastfeeding women (on the seventh day and at the end of one, two, three and four months after childbirth) allowed the researcher to gather data about the breastfeeding experience because the women’s recall was good. Conducting multiple interviews with the same women also enhanced the relationship between the women and the researcher, which allowed extensive information about their breastfeeding experience to be collected. This vast amount of material might not have been gathered if the data had been collected during one interview.

Finally, being a mother who breastfed her children provided an excellent way to deepen the researcher’s understanding of breastfeeding women’s experiences. The interaction between the women and the researcher contributed to a detailed interpretation of the data.

9.5.2 Limitations The findings of the study should be explained in the context of certain limitations. The limitations of this study include the limited transferability of the findings to other settings because the data were collected from one governorate in Oman. The participants were also recruited from one hospital and two health centres. Therefore, a more comprehensive study to explore a more extensive range of participants across various kinds of healthcare institution in different governorates should be performed to obtain comprehensive

261 information on breastfeeding from various governorates and to understand the similarities of breastfeeding experiences.

In this study, the researcher was an insider because she breastfed her children and has a background in breastfeeding as a nursing tutor who worked in the selected healthcare institutions during clinical practice. At the beginning of the data collection process, the researcher felt that it was challenging to separate her thoughts from the participants. This issue may have led to interviews that were guided by the researcher’s experiences. However, the researcher kept reflexive records of her assumptions throughout the research process to minimise her impact on the analysis of the data (Corbin and Strauss, 2014).

Furthermore, this study did not involve the husbands of breastfeeding women; husbands were invited but declined to participate. Some of the husbands declined because they did not consider breastfeeding to be their business and others apologised due to their place of work being outside the governorate under study and they could not travel to attend interviews. The involvement of the women’s husbands in this study might have contributed a more in-depth insight into breastfeeding support. Being able to include husbands’ perspectives would have added a further dimension to the research by exploring how they supported their wives while they were breastfeeding.

Another of the limitations of this study was that the majority of the women reported that healthcare professionals dealt negatively with them, but the researcher did not witness that behaviour during her observations. Thus, it is possible that the healthcare professionals did not show their typical behaviour because of the researcher’s presence, despite her explaining the aim behind conducting the observations.

Despite the limitations identified above, this is the first study of its kind in Oman and possibly in any GCC country. The results of this research study offer insights into and understanding of the viewpoints of breastfeeding women, their family members and healthcare professionals that may help further research studies on exclusive breastfeeding.

262 9.6 Recommendations for Practice, Policy, Education and Future Research

Perspectives surrounding exclusive breastfeeding were obtained in this research study by conducting interviews with a variety of participants. Observations were also conducted in different maternity settings to observe how healthcare professionals supported breastfeeding women. The findings chapters of this study provide a detailed description of the experiences and perceptions of exclusive breastfeeding from different viewpoints. This area of study requires further investigation to improve breastfeeding experiences and rates in Oman. Suggestions for practice, policy, education and future research are offered in the following sub-sections.

9.6.1 Practice

• Breastfeeding policy and guidelines are needed in healthcare institutions and all healthcare professionals should be informed of breastfeeding policy regularly. The necessity for women to be given breastfeeding support during the antenatal and postnatal periods should also be included in the job description of healthcare professionals.

• Breastfeeding programmes should be implemented to inform healthcare professionals, women and their family about breastfeeding, what to expect during breastfeeding, and how to support women during breastfeeding. The involvement of family members, particularly the children’s grandmothers, is vital because, within the Omani context, breastfeeding support is the grandmother’s role. This type of programme would enhance two aspects: (1) women’s ability to manage expectation; and (2) everyone concerned would be informed that breastfeeding support is not only the role of grandmothers, but also involves cooperative support between family members, healthcare professionals and the whole community.

• Healthcare professionals should be trained to educate and support women in breastfeeding during the antenatal and postnatal periods. It is essential to teach pregnant women breastfeeding techniques, as well as breastfeeding challenges and their management, during antenatal period visits.

263 • Healthcare professionals must listen to and discuss with women their needs and concerns regarding breastfeeding after childbirth, as this may help in finding solutions to breastfeeding challenges that could be scheduled during an antenatal appointment.

• Healthcare professionals should work with breastfeeding women to encourage the women in decision making with regard to continuing breastfeeding. This task could be accomplished by identifying women’s needs, building a trusting relationship, providing support and sharing concerns about breastfeeding. This could also be achieved by providing suitable and complete information about breastfeeding that could reduce women’s uncertainty and enable them to feel more empowered to breastfeed.

• Healthcare professionals should be trained in breastfeeding counselling. There should be breastfeeding champions and counsellors within maternity units who are dedicated to supporting breastfeeding women. The role of a breastfeeding counsellor is to assess breastfeeding women’s needs, provide support while breastfeeding and follow up the breastfeeding women.

• A telephone support service could be introduced in maternity units and healthcare professionals could assess breastfeeding difficulties over the phone. They would then be able to discuss issues related to breastfeeding over the telephone instead of face- to-face breastfeeding counselling if this is not needed or plan a follow-up appointment for breastfeeding counselling when required.

• Healthcare professionals should be trained in breastfeeding techniques and breastfeeding difficulties and their management so they can teach women during the antenatal and postnatal periods. Family members, such as the woman’s husband, mother and mother-in-law, should be involved in breastfeeding education. These classes are essential to empower women to overcome breastfeeding difficulties. Family members should also be encouraged to provide continuous support by encouraging them to visit the women after six weeks postnatal and provide as much assistance as they can. Healthcare professionals should encourage pregnant women to attend these classes.

264 9.6.2 Policy • Policy makers in the Ministry of Health should create a programme to train all healthcare professionals in breastfeeding counselling in all healthcare institutions.

• Policy makers should enhance active breastfeeding support by implementing breastfeeding classes during the antenatal period. They should also assign a small group to offer breastfeeding counselling and support in maternity units. It is also necessary to separate this group from the routine activities of the midwives. This group should prepare women for breastfeeding during the antenatal period by providing health education and practical support, such as offering advice on breastfeeding positioning and latching the baby to the breast and informing women of breastfeeding challenges and their management.

• Regular audits of women’s perceptions of and satisfaction with breastfeeding support in healthcare institutions would help policy makers to understand the situation. The feedback gained from this type of questionnaire should be used by policy makers in the MOH to foster the services given to breastfeeding women.

• Policy makers should plan private rooms for breastfeeding women to enable the women to breastfeed in public and in healthcare institutions.

• It is recommended that policy makers in Oman establish a breastfeeding policy for working women and determine a suitable time for women to return to work.

9.6.3 Education • This study demonstrated the need to develop an education programme for women on breastfeeding. This type of health education programme should go beyond the health benefits of breastfeeding and include practical instruction during the antenatal and postnatal periods on how to breastfeed.

• Healthcare professionals require education on breastfeeding and how best to support women.

265 • Since healthcare professionals do not know how to educate women during the breastfeeding period, they need training in breastfeeding counselling. This education programme should also be focused on giving emotional support during breastfeeding to enhance women’s resilience in overcoming breastfeeding challenges.

• Educational materials on breastfeeding and breastfeeding techniques and challenges should be provided to women during pregnancy. These materials should include essential aspects of breastfeeding support and women’s experiences of breastfeeding.

• All healthcare professionals should be informed of official breastfeeding policy, which should be displayed clearly in maternity units to allow all women to read it.

9.6.4 Future research • It is crucial to explore husbands perceptions of breastfeeding and breastfeeding support, with the aim of assessing their views relating to their role in supporting their wife during breastfeeding. A research study that includes husbands perceptions of breastfeeding may assist in forming strategies to improve ongoing breastfeeding support by fathers in Oman.

• Breastfeeding practice within the Omani context needs to be examined in different governorates in Oman in a future study, which would enable the results of this study to be compared with those of future research.

• Further research is required to explore the perceptions of working women to identify their experiences of breastfeeding, as well as to ascertain whether women who work are supported in their workplace in the governmental and private sectors in Oman.

• Further research is required to evaluate the interventions that have been suggested in this study.

9.7 In Closing

This research study has explored the experiences of breastfeeding women with regard to exclusive breastfeeding within the Omani context. It has also examined the perspectives of family members of the participants and healthcare professionals on breastfeeding,

266 including the support they provide to women during the breastfeeding period. There is no published literature on women’s experiences of EBF in GCC countries, and especially in Oman about exclusive breastfeeding. This research study provides novel insights into the EBF experience from different perspectives that could inform educational guidelines to promote the practice among women in Oman. The core category that emerged from the data has been identified as ‘Navigating the Reality of Breastfeeding’ and the emergent theory as ‘Resilience: The Power to Breastfeed’. The results show that the ability of women to breastfeed was dependent on women’s resilience. The analysis of the results has shown that different factors affected the women’s resilience in being able to adapt to breastfeeding difficulties.

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Appendices

304 Appendices

Appendix 1: Hawker’s Assessment Tool

Hawker’s Assessment Tool Appendix 4: (Hawker et al., 2002) Part A

Author and title: ______Date: ______

Good Fair Poor Very poor Comment 1. Abstract and title 2. Introduction and aims 3. Method and data 4. Sampling 5. Data analysis 6. Ethics and bias 7. Findings/results 8.Transferability/generalisability 9. Implications and usefulness

Good= 4 Fair = 3 Poor = 2 Very poor = 1

322 305

Part B: Assessment Criteria

1. Abstract and title: Did they Good Structured abstract with full information and clear title. provide a clear description of the study? Fair Abstract with most of the information. Poor Inadequate abstract. Very Poor No abstract.

2. Introduction and aims: Was Good Full but concise background to discussion/study containing up-to date there a good background and Literature review and highlighting gaps in knowledge. Clear statement of aim AND clear statement of the aim of the objectives including research questions. research?

Fair Some background and literature review. Research questions outlined. Poor Some background but no aim/objectives/questions OR Aims/objectives but inadequate background. Very Poor No mention of aims/objectives. No background or literature review.

3. Method and data: Is the Good Method is appropriate and described clearly (e.g., questionnaires included). Clear method appropriate and clearly details of the data collection and recording. explained? Fair Method appropriate, description could be better. Data described. Poor Questionable whether method is appropriate. Method described inadequately. Little description of data. Very Poor No mention of method, AND/OR. Method inappropriate, AND/OR No details of data.

4. Sampling: Was the sampling Good Details (age/gender/race/context) of who was studied and how they were recruited. strategy appropriate to address Why this group was targeted. The sample size was justified for the study. Response the aims? rates shown and explained. 323

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Fair Sample size justified. Most information given, but some missing. Poor Sampling mentioned but few descriptive details. Very Poor No details of sample.

5. Data analysis: Was the Good Clear description of how analysis was done. Qualitative studies: Description of how description of the data analysis themes derived/ sufficiently rigorous? Respondent validation or triangulation. Quantitative studies: Reasons for tests selected hypothesis driven/numbers add up/statistical significance discussed. Fair Qualitative: Descriptive discussion of analysis. Quantitative Poor Minimal details about analysis Very Poor No discussion of analysis.

6. Ethics and bias: Have ethical Good Ethics: Where necessary issues of confidentiality, sensitivity, and consent were issues been addressed, and what addressed. has necessary ethical approval Bias: Researcher was reflexive and/or aware of own bias. gained? Has the relationship Fair Lip service was paid to above (i.e., these issues were acknowledged). between researchers and Poor Brief mention of issues. participants been adequately Very Poor No mention of issues. considered?

7. Results: Is there a clear Good Findings explicit, easy to understand, and in logical progression. Tables, if present, statement of the findings? are explained in text. Results relate directly to aims. Sufficient data are presented to support findings. Fair Findings mentioned but more explanation could be given. Data presented relate directly to results. Poor Findings presented haphazardly, not explained, and progress logically from results. Very Poor Findings not mentioned or relate to aims.

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8. Transferability or Good Context and setting of the study is described sufficiently to allow comparison with generalizability: Are the other contexts and settings, plus high score in Question 4 (sampling). findings of this study Fair Some context and setting described, but more needed to replicate or compare the transferable (generalizable) to a study with others, PLUS fair score or higher in Question 4. wider population? Poor Minimal description of context/setting. Very Poor No description of context/setting

9. Implications and usefulness: Good Contributes something new and/or different in terms of understanding/insight or How important are these perspective. findings to policy and practice? Suggests ideas for further research. Suggests implications for policy and/or practice. Fair Two of the above (state what is missing in comments). Poor Only one of the above. Very Poor None of the above.

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Appendix 2: Assessing Studies Using Hawker’s Appraisal Tool Appendix 3: Assessing Studies Using Hawker’s Appraisal Tool

Included Studies Abstract Introduction Methods Sampling Data Ethics Findings Transferability Implications Total Scoring and and Aims and data Analysis and Bias / and Title generalizability usefulness Brouwer et al., 4 3 3 3 3 3 3 3 3 28 Good 2012 Chen, 2010 4 3 3 3 3 4 3 3 3 29 Good Chaput et al., 2015 3 3 4 3 3 4 4 3 3 28 Good Demirtas et al., 4 4 3 3 3 4 3 3 3 30 Good 2011 Hawley et al., 2015 3 3 3 3 3 4 3 3 3 28 Good Manhire et al., 2006 4 4 3 3 3 4 3 4 4 32 Good Spencer et al., 2014 3 4 3 3 3 3 3 3 3 28 Good Tarrant et al., 2014 4 4 3 3 3 3 3 3 3 29 Good Williamson et al., 3 4 4 3 3 4 3 3 3 30 Good 2011 Moore and Coty, 2 3 2 2 3 3 3 3 3 24 Fair 2006 Leurer and 4 4 3 3 3 4 3 4 4 32 Good Misskey, 2015 Obeng et al., 2015 4 4 3 3 3 3 3 4 4 31 Good Powell et al., 2014 4 4 4 3 3 4 4 3 4 33 Good Williamson and 4 4 4 3 3 4 3 3 3 31 Good Mohamed, 2012 Wandel et al., 2016 4 3 3 3 3 4 3 3 3 29 Good McBride-Henry et 3 3 3 4 3 3 3 3 3 28 Good al., 2009 Palmer et al., 2015 4 4 3 3 4 4 3 3 3 30 Good

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Hawker et al Score No. of reviewed studies Good: (28-36) 30

Fair: (19-27) 4

Poor: (10-18) 0 Very poor: (1-9) 0

311 Appendix 3: Summary and Characteristics of the Studies Included

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357 Appendix 4: Sample of Interview

Duration of the interview: 90 minutes (20 minutes to explain inform consent, obtain informed consent, information of demographic data and check the pink card of the baby and 70 minutes for the interview)

Introduction Zalikha: I want to thank you for taking the time to meet with me today. My name is Zalikha Al-Marzouqi Ph.D. student from the University of Manchester and I would like to talk to you about your experience on

breastfeeding. The interview may take more than one hour. I will

be taping the interview because I do not want to miss any of your comments. Although I will be taking some notes during the interview, I cannot possibly write fast enough to get it all down. All responses will be kept confidential. This means that your interview responses will only be shared with research team members and we will ensure that any information we include in our report does not

identify you as the respondent. Remember, you do not have to talk

about anything you do not want to and you may end the interview at any time. Are there any questions about what I have just explained?

Muluk: No, I don’t have any question now…smiling

Zalikha: Now, I will read the consent form to make sure that you understand the content… all points in the consent form will be read to you and if you have any question on any point please don’t hesitate to ask me and I will be pleased to answer your questions (after reading and explaining all points in the consent form)…. Are you interested to take part in this study.

Muluk: Yes, I want to take part in the study, no problem.

Zalikha: Thank you, then you have to sign 2 consent forms, one will be kept with you and one with me.

Muluk: Yes, I will sign.

*Demographic data, obstetrical and breastfeeding history were obtained from Muluk.

358 Interview Zalikha: The purpose of this interview is to learn more about your experience of breastfeeding. But before we talk about this could you please tell me about your experience of breastfeeding at X hospital?

Muluk: What can I say about my experience of breastfeeding…ammm…after childbirth I was tired and the midwives in labor room give me the baby…I was so tired … I was not able to carry my baby…mmmm… my mother helped me that time when the midwives asked me to breastfeed my child. After few hours I was shifted to postnatal ward I thought I will be more relaxed there and I may be able to sleep for some time. the midwives in the postnatal ward were only asking me to breastfeed my baby, I was tired that time and they did not even help me to put my baby at my breasts. Behind the curtain, they were asking me “did you feed you baby” I felt that they were only waiting for yes answer, I said, yes but I am tired…mmm… The midwives did not even ask me about my tiredness and why I feel tired. I was trying to feed my baby but it was difficult because I was powerless. The midwives only come in between to ask me “Did you feed your baby” they did not help me to breastfeed my baby….mmmm…without the help of my mother I would not be able to breastfeed my child.

Zalikha: What do you mean by the word powerless?

Muluk: I mean..aaaaa… I was really tired…mmm… you know after birth process I loss lots of blood and I did not sleep for 2 days before my childbirth, so I do not have energy to hold my baby that time to breastfeed her. I was asking for midwives help but they were not helping me in holding my baby or at least to bring my baby from her small bed. They were only asking to breastfeed my baby or if I breastfed my baby….mmmm… They were doing lots of works, I know, but that time I was really need some help or may be good words to reassure me and I was crying because I was afraid what will happen to my baby if I did not feed her…..mmmm…and midwives were not really helpful…I don’t know what to say.

Zalikha: Tell me more what do you mean by “you were afraid what will happen to your baby”?

Muluk: I mean that….aaaaa…. I was afraid if my baby will suffer from health problem like my older child because in my previous childbirth I did not be able to breastfeed my baby because I was tired and I loss lots of blood and my baby sugar level decrease too much and she had been admitted to the hospital for this reason. I was thinking that the same problem will happen for my new baby if I did breastfeed her. I was asking the help from midwives but they were not helping they are asking my mother to help me and they went for their job.

Zalikha: So, have you been able to breastfeed your baby at hospital?

359 Interview

Muluk: I was trying to breastfed my baby but I could not be able to breastfeed my baby…I could not be able to hold my baby and my mother was holding my baby to breastfeed… I breastfeed for short time and still my baby was crying the milk was not enough for her then my mother went to ask help from the midwives….aaaa…one midwife come eventually and she checked the level of sugar of my baby… it was low and she took my baby away from my room and gave her some milk..aaa.. I mean artificial milk. After that, my baby slept and I could be able to sleep that time for some time.

Zalikha: For how long did you try to breastfed your baby?

Muluk: I tried to breastfeed for almost one and half hour but no benefit…(phone rings)… My baby was crying all the time.

Zalikha Why were you not able to breastfeed your baby that time?

Muluk: Because I was tired and I need to sleep that time at least for 1 hour, I was also hungry that time and I need something hot to drink, the midwife provides me a cold drink which I did not really like to drink because that time I was really feeling cold and I need hot drink. Also, ammmm… my breasts were too big for the baby. I felt that my baby will suffocate and my mother was trying her best to help me to breastfeed my baby but I could not be able to breastfeed my baby because I could not be able to hold my breast.

Zalikha: Can you tell me please what do you understand from the word breastfeeding?

Muluk: mmmm… I think breastfeeding is when the mother gives her milk to the baby.

Zalikha: Can you expand a bit more on that? What breastfeeding is?

Muluk: I feel breastfeeding is prevention from diseases, it protects my baby from infections.

Zalikha: What do you mean by that?

Muluk: I mean…mmmmmm…breastfeeding help in increasing the immunity of my baby so she will not suffer from any illness…aaaaa…the breast-milk help the baby to be healthy unlike artificial milk it is not healthy and do not protect my baby from infection.

Zalikha: How do you know that?

360 Interview Muluk: I know from reading some booklets in the hospital and from my observation of my older daughter and my brother in low son… mmm…his mother did not breastfeed him at all and he always suffering from chest infections. He is all the time looks sick and…mmmm… He is now 2 years and he was admitted in the hospital so many times because of chest problem. So I put in my mind that breastfeeding is really good for the health of my babies. Also, when I am comparing my previous daughter with him, my daughter was physically healthy than him and she walked and talked before him…aaaa…she developed teeth before him and she looks health than him…I learned breastfeeding from my mother, she was the first one who taught me about the breastfeeding, she taught me everything about breastfeeding, she was my first source of information about breastfeeding….I think this is because of breastfeeding.

Zalikha: Can you expand more her?

Muluk: Yes…I mean my daughter speaks faster than my brother in low son. Also, aaaaaa…she walked and run before him…she grown much faster than my brother in low son and mentally she is ….aaaaa I feel more intelligence than my brother in low son.

Zalikha: Do you think this is because of breastfeeding?

Muluk: I think…aaaaa… yes and my daughter did not suffer from infections. Thus, I believe breastfeeding is good for the health of the babies.

Zalikha: Please could you tell me about your views on breastfeeding practices?

Muluk: What do you mean by breastfeeding practices?...mmmm.... I did not understand the word practices.

Zalikha: I mean… When do you start breastfeeding your baby? And Do you have any special practices while breastfeeding your child?

Muluk: I breastfed my baby after my birth for short time…..mmm…may be less that 5 minutes because I was tired and ….aaaa….I am usually breastfeeding my baby when she is crying.

Zalikha: Tell me please when exactly did you breastfeed your baby after your childbirth?

Muluk: I breastfeed my baby immediately when I delivered her…aaaaa….the midwife put my baby in my tommy and she went to finish her duty she did not come back to take the baby….mmm….then my mother asked my to breastfeed my baby… mmmm…. she said that I have to give the baby the yellow milk because it is good for the health of my baby. I breastfeed her for around 5 minutes only. I could not be able to continue because I could not hold the baby in my arm… I was really tired…..my mother

361 Interview was holding the baby so I manage feeding her for short time….mmmm… the midwives did not even help me during that time….before I left labour room one of midwives asked me only did you breastfeed you baby and that is all…. I was really frustrated.

Zalikha: What about you do you believe that yellow milk is really good for the health of the baby?

Muluk: mmmmm…I think yes….my mother always advising me to give the yellow milk to my baby so I think it is healthy….I trust my mother and I know that all the information that she will give me is good and beneficial either to me or my baby.

Zalikha: What about the midwives…mmmmm….I mean did she asked you to breastfeed your baby? Did the midwives asked you to give the yellow milk to the baby?

Muluk: No….she did not ask me to give the yellow milk to the baby….she did not help me even…I was tired and she did not even provide me a cup of water…they are in hurry all the time….I do not know what they are doing…but they did not help me when I need help…if my mother was not with me….I will not be able to drink a cup of water…my mother helped me to breastfeed my child…my mother help me to dress my baby and she helped me in carrying my baby…actually my mother helped me to change my dress and to take bath…not the midwives…before I left the labour room….a midwife came and she asked me if I breastfeed my child only and I said yes but I was tired….smiling…she did not even replayed to me..

Zalikha: Do you know why the yellow milk is healthy?

Muluk: mmm…smiling…I am not sure…. But I am listening to my mother advice. Smiling….. what I know it is good to protect my child from infection…..I am not sure…

Zalikha: You almost complete 1 week after child birth, Do you exclusively breastfeed your baby or do you provide other thing beside breastfeeding?

Muluk: Yes, I am breastfeeding my baby exclusively…mmm… I am also giving her some water with red seeds.

Zalikha: Why you are giving water with red seeds to your small baby?

Muluk: We believe that water with red seeds will clean the stomach and intestine of the baby so, the baby will pass motion normally after few days after childbirth and the black stool will be removed fast.

362 Interview Zalikha: For how long you are giving water with red seeds to your small baby?

Muluk: Usually, I am giving for… mmmm…7 to10 days after my childbirth.

Zalikha: What do you mean ‘black stool will be removed fast’? Can you explain?

Muluk: mmm..smiling…that mean the black stool will removed from my baby abdomen and my child will have normal colour of stool after few days after birth…mmmm…. Also, she will not have gases and abdominal distention. I think red seeds help my child to remove gases or abdominal distention.

Zalikha: What is black stool? I mean Don’t you think it is normal characteristic of the baby stool?

Muluk: It is normal but….mmmm.. the…mmm...I think when the baby swallowed the water of the abdomen when I was pregnant ...mmm…I think it produce black stool in my baby abdomen so, I think the red seeds are good to remove the black stool.

Zalikha: Ohh I see….mmm…now could you tell me about your experience of breastfeeding?

Muluk: mmm..I am breastfeeding my baby now for 7 days and this is good.

Zalikha: Do you enjoy breastfeeding your baby?

Muluk: Yes… when I am not tired, but when I am tired I don’t feel to breastfeed my child, I am thinking to give her artificial milk…

Zalikha: What do you mean not tired?

Muluk: mmmm…I mean when I have good sleep I am enjoying with breastfeeding but when I am not sleeping at night I feel tired to breastfeed my small baby.

Zalikha: How many hours do you sleep at night?

Muluk: mmm… it depends… sometimes 3 hours and sometimes 4…mmm… it depends on my baby….mmmm… She is crying all the night and not allowing me to sleep.

Zalikha: Why she is crying all the night? Do you know the reasons?

Muluk: mmmm…I feel she is hungry…she wants more milk but I don’t have enough milk…..mmm…I am not sure…

363 Interview Zalikha: How do you know that she is hungry?

Muluk: Smiling…mmmm…she is sucking the breasts and nothing is coming out from the breasts….she is moving her mouth and crying…she is hungry……I feel she is not getting enough milk…

Zalikha: Do you think, the position of baby is proper for breastfeeding?

Muluk: mmmm….I think yes, I am not srue… but I feel that my breasts are too big for my baby…..I feel that my breasts covers my baby face and I am afraid that she will suffocate.

Zalikha: Do you know how to breastfeed the baby…I mean you don’t have to be worried about the big breasts the baby will take part of breast… am I right?

Muluk: mmmm….yes …. I think you are right. I need to try again and again. May be after sometime she will be able to breastfeed.

Zalikha: When you were pregnant or after childbirth did the midwife show or educate you how to breastfeed your child?

Muluk: No, during my pregnancy she did not show me anything about the breastfeeding. She did once examination of my breasts only and I am not sure why she did that….mmm…the midwives in the labour room only asked me after childbirth if I breastfeed my baby….

Zalikha: What about leaflets or booklets on breastfeeding, did the midwife provide them to you?

Muluk: Yes, she gives me a leaflet to read in health centre but that time I was not interested to read, I was tired...I have shortness of breath…mmm...the midwife gives me the leaflet in the last month of my pregnancy….mmmmm… almost one week before my childbirth ….. I was not interested to read that time I was only thinking on my childbirth and the pain that I will feel.

Zalikha: What about your first child, did you breastfeed you daughter?

Muluk: Yes, I breastfeed her for almost 9 months.

Zalikha: So, this is not new experience for you.

Muluk: Yes, it is not new experience …you know my new child need to adjust to proper sleeping time which is suitable for me….mmm…. that time I think I will be relaxed.

364 Interview Zalikha: Do any one of your family member help you so you will sleep during the day time?

Muluk: Yes, my family members are helpful they help me to hold the baby and taking care of my child so, I will sleep for few hours during the day time…usually I am breastfeeding my baby then I will give them and they will play with her so, I will be able to sleep for longer time. They are really helpful.

Zalikha: Whom are the family member who help you in taking care of your child?

Sometimes my mother in low and sometime my husband…mmm… also Muluk: my sister in low helping me to carry my small baby when I want to sleep.

Zalikha: That is great….. So tell me what do you feel when you are breastfeeding your child?

Muluk: mmmm…what to say?....I am happy when I am breastfeeding my child and I feel that I am giving her something good for her health and she will be healthy in the future….mmmm…I am happy also because my family support me during the first month after my childbirth and they are always asking me to breastfeed my child so, I am breastfeeding her….my husband always asking me when he comes from his work ‘did breastfeed my daughter’ …and my mother in low also, asking me to breastfeed my daughter during the day. Thus, I am happy to do that because all are asking me to breastfeed and they are supporting me all the time and I feel that I must breastfeed my child.

Zalikha: So, how do you think your family member support or encourage you to breastfeed your child?

Muluk: mmm…I think when they are helping me to carry my small child and allowing me to sleep for few hours, I will be encouraged to breastfeed my small child…mmm...especially in the first month after my childbirth because I was tired to hold my daughter and I need some help in taking care of my daughter…aaaa… also when they are asking me to breastfeed ….aaa…I feel they wanted good thing to my daughter and good health for my daughter…mmm…so, I feel more encouraged to breastfeed my baby. My family helping me in all house hold activities so, I will not feel anxious about who will wash the clothes or who will cook and other things, they are helping me so, I am relax in the house….mmm….I feel that these ways helping me to breastfeed my child.

Zalikha: That is great really…..so tell me what do you think the helps or hinders of breastfeeding practice?

mmmm…for me I feel my family specially my husband play an Muluk: important role to encourage me to breastfeed my daughter….mmmm…he always asking me to breastfeed and when he is

365 Interview coming from his work he is always saying did you feed my daughter. He is also....mmmm…helping me in arranging the house and holds my baby for sometimes when I want to cook some food or when I want to take bath…mmmmm….he is also helping me when I want to change my small daughter dress or pampers. Also, when I want to give bath to the baby he holds her so, I feel relax when he is doing that… he is helpful.

Zalikha: That’s nice, what else that help you to breastfeed your baby?

Muluk: mmm….I don’t know..mmm….yes, my mother in low helps me also and carrying my daughter when I want to sleep during the day so, I feel this helps me to breastfeed my daughter and I will not feel tired….mmm.... and when I am awake she is also asking me to breastfeed my daughter so, I am breastfeeding her, she is encouraging me to breastfeed my child. Sometime, she is preparing food instead of me and she is asking me to relax specially when she observe that I am tired. Also, my sister in low, helping me by taking care of my older daughter, she is feeding her, changing pampers and giving bath to her and she is also changing her dress….mmm…I think these all helps me to breastfeed my daughter because somebody helping me.

Zalikha: What about you, do you feel that you want to breastfeed your child or you are breastfeeding when your husband and mother in low asking you?

Muluk: Yes ….mmm….off course I want to breastfeed my daughter.

Zalikha: So, tell me what makes you to breastfeed your daughter? What makes you encouraged to breastfeed your child?

Muluk: Smiling, aaaaaa....to be honest from my previous experience with my older child I felt breastfeeding help me in reducing my weight so, I wanted to breastfeed my new baby to reduce my weight …laughing…..also, to help my daughter to increase her weight….mmmm…and to be healthy as well…I don’t want my daughter to be affected by any diseases and breastfeeding helps my daughter to be healthy.

Zalikha: Is there anything else you would like to tell me about what helps you to breastfeed your child?

Muluk: mmmm… no…..mmmmm…. I feel my family member they are the one who help me to breastfeed my child like my husband, mother in low and my mother as well. My mother always sends to me good and healthy food which increase my milk production.

Zalikha: Can you expand her more, what do you mean by healthy food which increase your milk production.

366 Interview Muluk: Smile…I mean we have special food which are made only for the women who gave birth and this food is good for the health of the mother and it increase the production of milk like “helba”, “sikana”, “groos”, honey, fresh milk and vegetables.

Zalikha: For how long do you eat this type of food? And do you feel really it increase your milk production.

Muluk: For me I am eating this type of food for 40 days and really it is good for milk production. I feel my previous baby got enough milk to drink which make me happy and relax about her health. For this child still I need time so I will have enough milk. In my family, all women who delivered must receive this type of food because it is good for the health of women and the baby.

Zalikha: Is there anything else do you want to tell me?

Muluk: mmmm…I don’t think..smiling… no…

Zalikha: Okay… Can you tell me now about what hinders of breastfeeding practice? Muluk: Aaaa…I think if my family did not support and help me especially in the first days after my child birth I will not be able to breastfeed my baby. Their help and support encouraged me to breastfeed especially when I was tired after my child birth, I was not even able to carry my daughter and my mother was the one who carry my baby in the hospital so I breastfeed my baby.

Zalikha: What about the midwives, Don’t you think they are helpful to support you during breastfeeding in the hospital?

Muluk: mmm…no they were not helpful, I was tired and asking their help to breastfeed my baby. They did not help me. They were only asking me if I breastfed my child or asking me to breastfeed my child but I was in need for them to bring my baby. They asked my mother to help me….. no …. They are not helpful....they did not even support or encourage me…

Zalikha: What do you think other hinders of breastfeeding?

Muluk: mmmm…I think the tiredness is not allowing me to breastfeed…. When I am tired I don’t feel to breastfeed my baby…I don’t even think to breastfeed my baby....but when I don’t feel tired I wanted to breastfeed my daughter.

Zalikha: Is there anything else you would like to tell me about what hinder the breastfeeding practice?

367 Interview Muluk: Yes….I think the desire of the mothers…If mothers are interested to breastfeed their babies, they will do….but if they don’t want to breastfeed no one can force them to do…I mean …aaaa….it depend on mothers if they want or not to breastfeed…..for me I wanted to breastfeed when I was pregnant….I was planning to breastfeed my child and I discuss my desire with my husband…he encouraged me and support me from the beginning of my pregnancy.

Zalikha: Is there anything would you like to tell me?

Muluk: mmmm…..I am not sure……what I know if the mothers are knowledgeable of the importance of breastfeeding, they will be encouraged to breastfeed their babies and If mothers are not knowledgeable of the importance of breastfeeding they may not be encouraged to breastfeed their children.

Zalikha: What do you mean by knowledgeable?

Muluk: Well….mmmmm…I mean if the mothers have knowledge and information on breastfeeding, the importance of it, types of food which help the mothers to breastfeed…something like that…smiling….

Zalikha: From where do you think the mothers will gain these knowledge and information about breastfeeding?

Muluk: mmmm…from books…..mmmm….mainly from the midwives in the health center...aaaaa….or from internet…..

Zalikha: Do you think midwives are good source of information for breastfeeding?

Muluk: Yes…mmm…they are good source …but …I feel they are not doing well when giving education to me about breastfeeding….they are not talking in a good way…they are in hurry to finish the care…they are too fast when giving health education and brief….they gives me a leaflet on postnatal ward but they did not explain to me in-details about the breastfeeding…..they even don’t ask me If I understand the information…..they are telling only you have to breastfeed your baby and that is all….I feel I need more information…mmm…sometimes I don’t understand why my nipple is too small for my baby and how can I manage that…in the first day of my childbirth…I felt my breasts are too big and I was afraid that my child will be suffocated and I need to know what to do and….mmmm…when I ask the midwives….simple they did not do anything…they even did not tell me what to do…they are not interested to solve my problem.

368 Interview Zalikha: Ohhhh I see… is there anything you feel it is important that I understand about breastfeeding?

Muluk: mmmm… I don’t think….

Zalikha: I think this is the end of the interview….do you have any things to say …or do you have any question to ask…

Muluk: Smiling….no thank you….

Zalikha: Thank you for spending your time with me today and I hope to see you soon…

Muluk: You are welcome any time…I enjoyed talking in this interview.

Field notes:

Muluk welcomes me at her house. She was very happy from interview. I saw her older daughter and the new baby. She is living in a big house. It is clean house and they are in good economic states. In my country when visiting a woman with a new baby, it is must to take a gift for the baby, so I brought small gift for the baby and I gave a mother (Muluk) some flowers (I am not sure if this is good or bad for me as a researcher especially during data collection process). I feel that this is not belong to research process because it is a part of my culture.

It seems her family members are cooperative with her (I said that because when I was doing interview the new baby was with her mother in low and husband but when the baby need feed the mother in low give the baby to the mother to breastfeed her). Muluk is educated lady, she can access to internet and other source of information. She is a teacher teaching pre-school children. She has good communication skills. She looks happy with this new child and she looks interested to breastfeed her daughter. During the interview, Muluk’s mother in low brought the child and she asked her to breastfeed the child because she was crying. She breastfeeds the child in-front of me and she was happy to do that. She was playing with her new baby after feeding.

I feel the interview went fast and Muluk answered all my questions. I tried my best to get all information from her and to dig more and more to get all of her experience on breastfeeding. However, I remember she complete only 6 days after childbirth and still I have to do more interview with her if she allowed me. So, after interview I told her that I will contact her to do anther interview to know her experience. The only thing that I was not happy of is her older daughter was with us during the interview and she was playing her and there so, the mother was trying to calm her and to keep her quite. I asked the mother to go to calm room to continue the interview. The mother took her daughter to her sister. I apologised for my request at the end of the interview and the mother said “no worries”.

369 Appendix 5: Timing of interviews and Breastfeeding Cessation

Women’s Interview Interview Interview 3 Interview 4 Interview 5 Interviews 1 2 (2ndMonths) (3rd Months) (4th Months) Dates and BF (7th day) (1st Month) cessation/ nick name 1. Muluk 18/12/2016 08/01/2017 05/02/2017 05/03/2017 01/04/2017 (Stopped Breastfeeding) 2. Moon 23/12/2016 13/01/2017 10/02/2017 09/03/2017 X (Stopped Breastfeeding) 3. Rose 28/12/2016 18/01/2017 16/02/2017 X X (Stopped Breastfeeding) 4. Safi 31/12/2016 22/01/2017 22/02/2017 25/03/2017 10/04/2017 (Stopped Breastfeeding) 5. Star 12/01/2017 10/02/2017 0/03/2017 10/04/2017 10/05/2017 (Stopped Breastfeeding) 6. Noor 20/01/2017 12/02/2017 12/03/2017 11/04/2017 X (Stopped Breastfeeding 7. Nada 22/01/2017 16/02/2017 16/03/2017 16/04/2017 19/05/2017

8. Sweet 23/01/2017 17/02/2017 17/03/2017 X X (Stopped Breastfeeding) 9. Somi 27/01/2017 21/02/2017 21/03/2017 21/04/2017 21/05/2017 (Stopped Breastfeeding) 10. Anwar 01/02/2017 25/02/2017 25/03/2017 25/04/2017 25/05/2017

11. Nawal 07/03/2017 01/04/2017 01/05/2017 01/06/2017 01/06/2017

370 Appendix 6: Topic Guide for Postnatal Mother Interview

Date: Interview No: Infant age (months/days):

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016 Topic Guide Postnatal Mothers: Interview

Check: date, venue (not noisy), tape conversation – permission, extra batteries, anonymous, use of quotations – but these will be anonymous, not to name individuals, can withdraw at any time after consent.

Introduction: I want to thank you for taking the time to meet with me today. My name is Zalikha Al-Marzouqi and I would like to talk to you about your experience on breastfeeding. The interview will take more than an hour. I will be taping the session because I do not want to miss any of your comments. Although I will be taking some notes during the interview, I cannot possibly write fast enough to get it all down. All responses will be kept confidential. This means that your interview responses will only be shared with research team members and we will ensure that any information we include in our report does not identify you as the respondent. Remember, you do not have to talk about anything you do not want to and you may end the interview at any time. Are there any questions about what I have just explained?

Obtain information of demographic data, obstetrical, breastfeeding history. The purpose of this interview is to learn more about your experience of breastfeeding. But before we talk about this could you please tell me about your experience of breastfeeding at hospital? Can you tell me please what do you understand from the word breastfeeding? Please could you tell me about your views on breastfeeding practices? Please could you tell me about your experience of breastfeeding? Is there anything you feel it is important that I understand about breastfeeding?

Probes: Tell me what do you mean by……………. In what way………… Can you expand a bit more on that? Are there any other reasons?

Thank you very much…

371 Appendix 7: Topic Guide for Postnatal Mother Interview (Update)

Date: Interview No: Infant age (months/days):

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016 Topic Guide (updated) Postnatal Mothers: Interview

• Obtain information of demographic data, obstetrical, breastfeeding history. • The purpose of this interview is to learn more about your experience of breastfeeding. But before we talk about this could you please tell me about your experience of breastfeeding at hospital? • Can you tell me please what do you understand from the word breastfeeding? • How do you know about breastfeeding? • From whom you learn about breastfeeding and breastfeeding practice? • Please could you tell me about your views on breastfeeding practices? • Please could you tell me about your experience of breastfeeding? • Please can you tell me about family support for breastfeeding? • Can you tell me please about healthcare professionals support for breastfeeding? • What kind of support do you need from your family members? • What kind of support do you need from healthcare providers? • Do you feel comfortable from the way of support provided by your family members and / or healthcare providers?

372 • What difficulties did not experience while initial breastfeeding? • Can you tell me please about breastfeeding in public? • What do you think the helps of breastfeeding practice? • What do you think the hinders of breastfeeding practice? • Is there anything you feel it is important that I understand about breastfeeding?

Probes: • Tell me what do you mean by……………. • In what way………… • Can you expand a bit more on that? • Are there any other reasons?

Thank you very much…

373 Appendix 8: Topic Guide for Family members of Women’s Participants

Date: Interview No: Relationship to mother:

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016

Interview Guide

Family Member of the Postnatal Mothers: Interview

Check: Date, Venue (not noisy), Tape conversation – permission, extra batteries, anonymous, Use of quotations – but these will be anonymous, not to name individuals, can withdraw at any time.

Introduction: I want to thank you for taking the time to meet with me today. My name is Zalikha Al-Marzouqi and I would like to talk to you about your views and perspectives on breastfeeding. The interview will take more than an hour. I will be taping the interview because I do not want to miss any of your comments. Although I will be taking some notes during the session, I cannot possibly write fast enough to get it all down. All responses will be kept confidential. This means that your interview responses will only be shared with research team members and we will ensure that any information we include in our report does not identify you as the respondent. Remember, you do not have to talk about anything you do not want to and you may end the interview at any time. Are there any questions about what I have just explained?

Questions:

• I would like to hear about your views on breastfeeding? What do you understand from the term breastfeeding? • Could you please tell me about your thinking of what support the mother needs when she is breastfeeding her baby? • Could you please tell me about the type of support that family can give to support breastfeeding mothers? • Can you tell me what do you think about the benefits and disadvantages of breastfeeding?

374 Probes:

• Tell me what do you mean by……………. • In what way………… • Can you expand a bit more on that? • Are there any other reasons?

Thank you very much…….

375 Appendix 9: Topic Guide for Healthcare Professionals Interview

Date: Interview No: Health Institution:

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016

Interview Guide

Healthcare Professionals: Interviews

Check: Date, Venue (not noisy), Tape conversation – permission, extra batteries, anonymous, Use of quotations – but these will be anonymous, not to name individuals, can withdraw at any time.

Introduction: I want to thank you for taking the time to meet with me today. My name is Zalikha Al-Marzouqi and I would like to talk to you about your views and perspectives on breastfeeding. The interview will take more than an hour. I will be taping the session because I do not want to miss any of your comments. Although I will be taking some notes during the session, I cannot possibly write fast enough to get it all down. All responses will be kept confidential. This means that your interview responses will only be shared with research team members and we will ensure that any information we include in our report does not identify you as the respondent. Remember, you do not have to talk about anything you do not want to and you may end the interview at any time. Are there any questions about what I have just explained?

Give Questionnaire to the midwives to complete.

Questions:

• I would like to hear about your views or perspectives on breastfeeding, tell me please about it? • Can you tell me please what support does the mother require when she is feeding her baby? • Could you tell me please about your perspectives on the baby friendly hospital initiative?

376 Probes:

• Tell me what do you mean by……………. • In what way………… • Can you expand a bit more on that? • Are there any other reasons?

Thank you very much….

377 Appendix 10: Sample of the Clinical Observation

Non- Participant Observation Schedule of Breastfeeding support in the Labour Room Baseline data:

Type of observation: Non - Participant observation.

Name of health facility: (Labour room).

Date observation commenced: 22 May, 2017.

Time observation commenced: 10:00 AM. Post birth 10 minutes.

Time observation finished (observations should last 1 hour approximately): 11:00 AM.

Name of observer completing form: Zalikha Al-Marzouqi.

General information about breastfeeding: (from records) Ie first feed? Previously breastfed?

In this observation, the researcher observed woman (who gave birth), grandmother and midwife who conducted the birth process. Woman was breastfeeding for the first time.

Details regarding woman: (from records)

A primi woman, 21 years old, woman complete secondary school certificate. Woman is full term, Gravida 1, para 1. Suture done (Episiotomy) for the woman. No history of medical illness, no history of surgical intervention. No complications during labour. Woman is in a good health condition. She spends 17 hours during labour process. Woman gave birth to baby boy, baby is in a good health condition and kept with the woman in the same room. Woman is speaking Arabic language.

Details regarding midwife: (from in charge of labour room – after observation).

Omani midwife conducted the labour for the woman (who were observed). She was speaking Arabic language. She has 9 years’ experience in the labour room. Graduated from Specialized nursing institute in one region in Oman and she has midwives certificate from 2008.

378 Details regarding the non - participant observation

Time of birth (from records) 09:50 AM.

Time of skin to skin contact Immediately after birth, time was not recorded. Just (form records) written at Green card and woman records (Skin to skin contact immediately after birth).

General health of the mother Woman looks tired, she looks pale. Her facial expression indicates that she is on pain. She is putting her hand on her abdomen and pressing her lips and closing her eyes. Her lips are dried and her eyes are red colour. She is on the bed and the cover of the bed has some blood on it. She was quite all the time and when the midwifes or grandmother asking her, she was answering their question briefly. She was sleepy and she was yawning all the time.

Time of first breastfeeding 10:20 AM breastfeeding was started for 10 minutes after childbirth only.

Initiate breastfeeding by Grandmother was initiated breastfeeding for the (Midwife, Mother, family woman who gave birth. members)

Anatomy of the breasts At 10:20, woman started breastfeeding her baby. Her (Breasts condition) breasts condition is good and healthy. Her nipples were prominent. No abnormal features were noted in the skin of the breasts. No redness and no lesions were noted. Breasts look healthy.

Condition of the mother in Woman wanted to breastfeed her baby and she was regards to breastfeeding trying to hold the baby and breastfeed him but it seems that she is so tired and she cannot hold the baby for breastfeeding. Grandmother was helping the woman (who gave childbirth) by holding the baby so woman can breastfeed her baby. The grandmother was instructing the woman on how to breastfeed the baby and how to hold the baby correctly.

Baby responses to the breast Baby was feeling sleepy and he was sleeping while breastfeeding when woman started breastfeeding him and grandmother was trying to make him awake by pressing on the baby’s hands and legs with grandmother fingers. But baby was not breastfeeding and he went to sleep again.

379 Assessment of mother In the first attempt of breastfeeding, woman was breastfeeding experience finding difficulty with breastfeeding. She was (enjoying, finding difficult) struggling to breastfeed her baby. She was not able to hold the baby because she was tired and she does not know the proper position of breastfeeding. Woman was saying to the grandmother “I do not know how to put my baby on my breast”. Woman was upset (facial expression was sad) when the baby is not breastfeeding well and she was putting her head (backward) on the pillow and it seems that she is upset and not happy. Woman’s mother (grandmother) taught her daughter about breastfeeding, woman was pleased when she was doing well when breastfeeding her baby.

Baby’s sucking Sometimes baby was sucking well the breast for few seconds and sometimes he is not sucking at all because of baby was sleepy and because woman said that she does not know how to put the baby on her breast (improper position of the breastfeeding). Woman has difficulty to hold the baby and to put him near her breast because she was tried.

Termination of the feed After 10 minutes, woman terminated the first attempt of breastfeeding because the baby was sleeping and he was not sucking her breast and she was tired and sleeping as well.

(length) Time of midwife After Episiotomy, midwife left the room for presence in the labour room documentation and she kept the woman on the bed after childbirth and the baby on his small bed. Midwife entered the room when the grandmother called her because the woman could not be able to breastfeed her baby in the first attempt.

Midwife teaching, help and Midwife did not teach the woman on breastfeeding. support on breastfeeding She did not teach the women how to hold the baby with one hand and how to hold the breast with the fingers of other hand.

(length) Time of Midwife did not teach or observe the woman during breastfeeding teaching by breastfeeding. The midwife asked grandmother to the midwife observe the woman during breastfeeding and if there are any problem, she has to call the midwife in the reception.

Midwife behaviour Midwife was smiling and she was kind with the woman and she offered a cup of tea and some sandwiches to the woman at 10:45 AM. Midwife did not encourage the woman to breastfeed.

380 Educational material No health education materials provided by the provided by the midwife midwife about breastfeeding.

Present of family member Grandmother was with the woman during the first with mother during attempt of woman for breastfeeding. The breastfeeding grandmother asked the woman to start breastfeeding her baby because she said that “he is hungry”.

Types of family members’ Grandmother was with the woman all the time and helps and support for she was teaching the woman how to hold the baby and breastfeeding how to insert the nipple and part of breast into the baby’s mouth. She was helping the woman to set down and to hold the baby. She was telling the woman the importance of breastfeeding for the baby and for the woman. She was supporting the woman and encouraging her to breastfeed the first milk to the baby and she was explaining to the woman the importance of first milk to the baby. The grandmother was telling the mother her own experience on breastfeeding when she was young. The grandmother was encouraging the woman and telling her good words like “I know you will do well with breastfeeding because you are my daughter” “well done”.

Please write about any unexpected events here:

-Woman initiated breastfeeding in the first hour after birth because the woman failed in breastfeeding in the first attempt. Woman success breastfeeding after 40 minutes. -It is not allowed to eat food or bring food from outside the labour room and food was too late for the woman after childbirth. -Husband was not allowed to enter to labour room to see the baby because of cultural issue. -Midwife was not in the labour room with the woman after episiotomy. She was in the reception for documentations. During observation, midwife was with the woman for 5 minutes and perform physical examination for the baby. Midwife entered the labour room to tell the woman to take bath and she spend in the room for few second only.

381 Detailed Observation in labour room (after childbirth)

Time Observation

10:00 AM There was woman who give birth and grandmother in the labour room. Woman was on the bed and she was wearing a hospital gown (pink colour). It seems that she is tired and wanted to sleep because she was yawning. Her face expression indicates that she was on pain because she was closing her eyes, pressing on her lips and holding the abdomen with her left hand. She was not able to move on her bed and she was asking the help from her grandmother when she wanted to change her position (laying down from right side to left side). No midwife was in the room. Midwife went to the reception for documentation. Baby was sleeping on his small bed beside the woman’s bed.

10:05 AM Woman was laying down on her bed on the left side. She asked her woman some water to drink and grandmother provided some water to the woman. The grandmother provided some milk to the woman to drink but she refused because “she wanted to sleep and she was tired” (woman said). Midwife entered the room and she asked the woman to take the bath but the woman refused and she said that she will take the bath after some time. Midwife spend few seconds in the labour room. Midwife went out from the room.

10:10 AM Midwife was not in the room. Grandmother asked the woman to start breastfeeding and she said the woman “your baby is hungry”. The grandmother helped the woman to set down on the bed and she took the baby from his small bed which was beside the woman’s bed. The grandmother gave the baby to the woman to start breastfeeding. The woman initiated breastfeeding with difficulties. The woman does not know how to position the baby for breastfeeding and she does not know how to hold the baby to initiate breastfeeding. Woman said that “she does not know how to put the baby on her breast”. The woman was trying to breastfeed her baby but she was not able to breastfeed because the baby was not sucking well and he was sleepy. The grandmother was trying to make the baby awake by pressing on his hands and legs but the baby was not responding. Grandmother said to the woman that “you need to press on baby’s leg and hands to make him awake so he can breastfeed”. When the baby was awake for some times (one or two minutes), the grandmother was teaching and helping the woman to breastfeed her baby but the woman could not be able to breastfeed the baby and she was upset (woman’s face indicated that she was sad). After 5 attempts of breastfeeding, grandmother said that she will call the midwife. Woman attempts first breastfeeding for 10 minutes but she could not breastfeed her baby because baby is not sucking well and he was sleepy. One time the baby sucks the breast for few second and after that he did not suck the breast. Then, the grandmother told the woman that she will put the baby on his small

382 bed and she took the baby from the woman and she put him on his small bed beside the woman’s bed. She covered the baby. The baby was sleeping. Grandmother went outside the labour room to call the midwife.

10:20 AM Grandmother went to call the midwife. The woman was sleeping on her bed (supine position). The grandmother arrived after 5 minutes and she offered a cup of juice for the woman. The woman drunk the juice and she slept again. No midwives entered the room that time. The woman was sleeping nicely and the baby was sleeping. The grandmother was setting on the chair and in between she was going outside the room to call the midwife. No midwife entered to the labour room for 25 minutes.

10:45 AM The midwife who conducted the labour (childbirth) entered the labour room and she was smiling. She was kind with the woman and she offered a cup of tea and some sandwiches to the woman. Woman said that she “will eat later”. Midwife asked the grandmother to bring the baby from his small bed and to give the baby to the woman. The grandmother took the baby from the bed and give him to his mother. Then, the midwife asked the grandmother to ask her daughter to start breastfeeding and she left the room. The grandmother was near the woman on the right side of the bed and she was too close to the woman. The woman exposed her left breast and she hold the baby on her left hand. Woman supported the head of the baby by her left hand and she hold the left breast with right hand (fingers). She was trying to insert the nipple and the areola with her hand but the baby was not sucking the breast. The grandmother was instructing the woman on how to hold the baby correctly because the baby was not supported well for breastfeeding. She was telling the woman to hold to hold the baby with her left hand and to hold the left breast with the right hand (fingers). She was telling the woman to insert the nipple and areola into baby’s mouth and she said if “you did not insert properly the nipple and areola; you will develop nipple sore”. Also, the grandmother was teaching the woman to insert the nipple and areola and how to stimulate the baby’s lip (one side). She said to woman to stimulate the baby’ s mouth by her finger. She was bending herself to teach the woman on how to breastfeed the baby and she demonstrated in front of the woman how to breastfeed the baby. The woman was trying to do what her mother asked her to do but the baby was not sucking and baby was sleeping. Grandmother pressed strongly the heel of the baby’s leg. Then baby cried and got awake. Woman was trying again to put the baby near her breast and baby was trying to breastfeed. Woman was listening and seeing carefully. Grandmother was telling the woman to hold the baby with her left hand and to hold the left breast with the right hand (fingers). She was telling the woman to insert the nipple and areola into baby’s mouth and she said if “you did not insert properly the nipple and areola; you will develop nipple sore”. Grandmother was clear on instructing the woman on how to breastfeed the baby but she was very brief on instructing the woman,

383 she did not give detailed information and she spend only few minutes to teach the woman. Woman was trying to breastfeed her baby several times (3 times). After the third attempts, woman was able to breastfeed her baby nicely and baby started sucking the breast well. Grandmother said to her daughter that she need to try several times because woman is breastfeeding for the first time. Grandmother said to the woman that “you will be able to breastfeed the baby successfully”. Woman was smiling and said that she will do. 10:50 AM Woman was breastfeeding her baby. The baby was breastfeeding well and it seems that the woman is very happy (Woman was smiling, facial expression) and she was smiling and looking to her baby. Woman said to the grandmother that “Her baby is breastfeeding and she will give him her milk”. The grandmother was with the woman talking to her and encouraging her by telling the woman the importance of the yellow milk for the baby and she said that “Yellow milk will protect your baby from diseases”. She was encouraging the woman to continue breastfeeding the baby until the yellow milk over and to then to breastfeed the baby with the white milk. She was saying to her “I am proud of you and I know that you will breastfeed your baby”. She was explaining to the woman the importance of breastfeeding to the woman and she said that breastfeeding will help your uterus to regain to its normal position”. Woman was so happy and she said to her mother that I will breastfeed my baby. Woman was breastfeeding her baby for 15 minutes continuously. The baby released the breast by his own self after 15 minutes and he went to sleep again. The woman was so happy and she was smiling to her baby. The grandmother took the baby from the woman and she put him on the small bed.

11:05 AM Baby was sleeping on his bed. Woman was setting on her bed and she asked her mother to give her some sandwiches to eat. Woman eat the sandwiches and drunk some juice. Woman went to take bath after she eat the sandwiches. The grandmother was in the labour room and she was waiting for the woman to come out from the bathroom.

384 Field Note

- I felt that woman was upset and sad when she was not able to breastfeed her baby during the first attempt. - I felt that midwife was outside the labour room for long time and she was only entering the room when one of the family member call her or when she wants the woman to do something like taking a bath. - I felt that woman was too happy when she was breastfeeding her baby and she was looking to her baby. - midwife did not teach the woman about breastfeeding and she was busy with documentation. She did not observe the woman while breastfeeding. I think for woman needs detailed explaination about breastfeeding. - I felt that food was too delayed and the woman needs food early after childbirth to regain her power. Food will help the woman to have some power for breastfeeding. - I think that family members of the woman are more supportive to the woman in regards breastfeeding than midwives. - No woman attended any antenatal class in regards to breastfeeding during ante natal period. No health education conducted about breastfeeding after childbirth. - Green card is maternal card which is giving to pregnant women during ante natal period until postnatal period (6 weeks postnatal). In this card, the health condition of women is written down with investigation and midwives and doctors notes.

385 Appendix 11: Observation Guide

Name of Setting: Observation No:

Observation

Attitude and Behaviour of Midwives

Context and Environment

386 Breastfeeding Support

Communication

Health Education and Educational Materials

Other Observations:

387 Appendix 12: Observation Sheet (Update)

Non- Participant Observation Schedule

Baseline data:

Type of observation:

Name of health facility:

Date observation commenced:

Time observation commenced:

Time observation finished (observations should last 1 hour approximately):

Name of observer completing form:

General information about breastfeeding: (from records) Ie first feed? Previously breastfed?

Details regarding woman: (from records)

Details regarding midwife: (from in charge of labour room – after observation).

388

Details regarding the non - participant observation

Time of birth (from records

Time of skin to skin contact (form records) General health of the mother Time of first breastfeeding after childbirth

Initiate breastfeeding by (Midwife, Mother, family members) Anatomy of the breasts (Breasts condition) Condition of the mother in regards to breastfeeding Baby responses to the breast

Assessment of mother breastfeeding experience (enjoying, finding difficult) Baby’s sucking Termination of the feed (length) Time of midwife presence in the labour room after childbirth Midwife teaching, help and support on breastfeeding (length) Time of breastfeeding teaching by the midwife Midwife behaviour Educational material provided by the midwife Present of family member with mother during breastfeeding Types of family members’ helps and support for breastfeeding Please write about any unexpected events here:

389 Detailed Observation

Time Observation

Observation Field Notes

390 Appendix 13: Example of Initial Coding with NVivo

391 Appendix 14: Ethical Approval Research Ethics Committee at the UOM

Ref: ethics/16346 Research Governance, Ethics and Integrity nd 2 Floor Christie Building Prof Dame Tina Lavender The University of Manchester Division of Nursing, Midwifery & Social Work Oxford Road Room 4.323 / Jean McFarlane Building Manchester The University of Manchester M13 9PL Tel: 0161 275 2206/2674 1st September 2016 Email: [email protected]

Dear Prof Dame Tina Lavender,

Study title: Talking to Omani Mothers About Breast Feeding

Research Ethics Committee 4

I write to thank Ms Al-Marzouqi for coming to meet the Committee on 27th July 2016. I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the application form and supporting documentation as submitted and approved by the Committee.

This approval is effective for a period of five years. If the project continues beyond that period an application for amendment must be submitted for review. Likewise, any proposed changes to the way the research is conducted must be approved via the amendment process (see below). Failure to do so could invalidate the insurance and constitute research misconduct.

You are reminded that, in accordance with University policy, any data carrying personal identifiers must be encrypted when not held on a secure university computer or kept securely as a hard copy in a location which is accessible only to those involved with the research.

Reporting Requirements: You are required to report to us the following:

1. Amendments 2. Breaches and adverse events 3. Notification of Progress/End of the Study

Feedback It is our aim to provide a timely and efficient service that ensures transparent, professional and proportionate ethical review of research with consistent outcomes, which is supported by clear, accessible guidance and training for applicants and committees. In order to assist us with our aim, we would be grateful if you would give your view of the service that you have received from us by completing a feedback sheet UREC4 feedback

We hope the research goes well.

Yours sincerely,

Karen Lythe Secretary to University Research Ethics Committee 4

392 AppendixAppendix 5:15 Ethical: Ethical Approval Approval Research Research Ethics Ethics Committee Committee in the Ministryin the MOH of Health in Oman In Oman

393 Appendix 16: Postnatal Mother Advertisement Interview (English and Arabic) Appendix 42: Postnatal Mother Advertisement Interview (English and Arabic)

ا ل ت ح د ث م ع المهات العمانيات عن الرضاعة الطبيعية

ه ل ترغب في مشاركة آرائك ع ن الرضاعة الطبيعية؟ أ ن ا ابحث عن آ ر ا ء المهات ع ن الرضاعة الطبيعية وأنا سعيدة لسماع ما تقولون .

أ ن ت م سوف تنتقون من م س ت ش ف ى ق س م م ا ب ع د الولدة م ن قبل القابلت . وسوف تشملون في المراقبة إ ذ ا تطلب المر .

إ ذ ا ا ر د ت المزيد م ن المعلومات ل تترددي بالتصال ع ل ى ا ل ق ا ب ل ة المسؤولة عن ا ل ت ج ن ي د في ق س م م ا ب ع د الولدة.

Would you like to share your views on breastfeeding?

I am researching mothers’ opinions on breastfeeding and am keen to hear what you have to say.

Soon, I will be asking volunteers to speak to me about this.

You might be included in observation if needed.

If you want any further information, Please contact the gatekeepers in the postnatal ward.

394 Appendix 17: Postnatal Mother Advertisement Observation (English and Arabic)

Appendix 43: Postnatal Mother Advertisement Observation (English and Arabic)

مراقبة المهات المرضعات في مؤسسات الرعاية الصحية

ه ل ترغب في مشاركة آرائك ع ن الرضاعة الطبيعية؟

أ ن ت م سوف تنتقون من م س ت ش ف ى من ق ب ل القابلت . وسوف تشملون في المراقبة لمراقبة ك ي ف ي ة د ع م القابلت ل ل ن س ا ء المرضعات .

Observing breastfeeding women in the healthcare institutions

I am researching breastfeeding women who agree to participate in observation. The purpose of observation is to observe how healthcare professional support breastfeeding women in the healthcare institutions.

Soon, I will be asking volunteers.

If you want any further information, Please contact the gatekeepers in the postnatal ward.

395 Appendix 18: PIS for Postnatal Mother/ Interview (Arabic)

ثﺪﺤﺘﻟا ﻊﻣ تﺎﮭﻣﻻا تﺎﯿﻧﺎﻤﻌﻟا ﻦﻋ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا راﺪﺻﻹا لوﻻا ﺎﻣ ﻮﯾ ٢٠١٦ جذﻮﻤﻧ ﻌﻣ تﺎﻣﻮﻠ ﻦﯿﻛرﺎﺸﻤﻠﻟ - تﺎﮭﻣﻸﻟ ﺪﻌﺑ ةدﻻﻮﻟا

فﻮﺳ ﻢﺘﯾ ﻮﻋد ﻚﺗ ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ رد ﺔﺳا فﺎﺸﻜﺘﺳاو تاﺮﺒﺨﻟا ءارﻵاو ﻦﻣ ءﺎﺴﻨﻟا تﺎﯿﻧﺎﻤﻌﻟا ﻲﺗﻻا ﻦﻌﺿﺮﯾ . دواو نا ثﺪﺤﺗا ﻢﻜﯿﻟا ﺪﻌﺑ ٧ مﺎﯾا ﻦﻣ دﻻو ة ﻔط ،ﻚﻠ ﻢﺛ ةﺮﻣ يﺮﺧا ﻲﻓ ١،٢،٣و ٤ ﺮﮭﺷأ ﺪﻌﺑ دﻻو ة ﻔط ﻚﻠ ( اذا نﺮﻌﺷ تﺎﮭﻣﻻا نا ٥ ﻘﻣ ﺎ تﻼﺑ ھﺮﻣ ﻘ ﮫ ، ﻦﮭﺘﻋﺎﻄﺘﺳﺎﺒﻓ ﻞﻤﻋ ١ وا ٢ وا ٣ وا ٤ وا ٥ ﻘﻣ ﺎ ،تﻼﺑ اذا ﻏر ﺒ ﻦ ﻚﻟذ ) . ﻰﺟﺮﯾ اﺮﻗ ةء تﺎﻣﻮﻠﻌﻤﻟا ﺔﯿﻟﺎﺘﻟا ﻦﻋ ﺔﺳارﺪﻟا ﻨﻌﺑ ﺎ ،ﺔﯾ ﻻو ددﺮﺘﺗ ﻓﻲ حﺮط يا ﺆﺳ ا ل وأ ﻨﻣ ﺎ ﺔﺸﻗ يأ ﻌﻣ ﻠ ﺔﻣﻮ ﻦﻋ ﺔﺳارﺪﻟا . ﻤﻛ ﺎ ﻚﻨﻜﻤﯾ نأ ﺶﻗﺎﻨﺗ ﺤﻣ ﺘ ىﻮ ﺔﺳارﺪﻟا ﻊﻣ ﺒط ﯿ ﻚﺒ وأ داﺮﻓأ ﻚﺗﺮﺳأ رﺮﻘﺘﻟ ﺎﻣ اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺔﺳارﺪﻟا . ﻢﻛﺮﻜﺷأ ﻰﻠﻋ ﻗو ﻢﻜﺘ ةءاﺮﻘﻟ رو ﻗ ﮫ تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ يﺮﺠﯿﺳ ؟ﺚﺤﺒﻟا ﺎط ﻟ ﺒ ﺔ هارﻮﺘﻛﺪﻟا ﻟز ﺔﺨﯿ ،ﻲﻗوزﺮﻤﻟا ﺔﻠﺻﺎﺣ ﻰﻠﻋ ﺑد مﻮﻠ ﻤﺗ ﺾﯾﺮ ﺎﻋ م ١٩٩٩، ﺎﻜﺑ سﻮﯾرﻮﻟ ﺾﯾﺮﻤﺗ ﺎﻋ م ٢٠٠٢، ﻣو ﺘﺴﺟﺎ ﺮﯿ ﻲﻓ تﺎﺳرﺎﻤﻤﻟا ﺔﯿﻨﮭﻤﻟا ﺎﻋ م ٢٠٠٧ . ﺎﺣ ﻟ ﯿ ﺎ ﺚﺣﺎﺒﻟا سرﺪﻣ ﺾﯾﺮﻤﺗ ﻲﻓ ﺪﮭﻌﻣ ﻤﺷ ﺎ ل ﺔﻨطﺎﺒﻟا ﺾﯾﺮﻤﺘﻠﻟ . . ﺎﻣ ﻮھ ضﺮﻐﻟا ﻦﻣ ﺬھ ا ؟ﺚﺤﺒﻟا فﺪﮭﺗ ﺬھ ه ﺔﺳارﺪﻟا ﻰﻟا ﺬﺧأ ءارآ ﮭﺟوو تﺎ ﺮﻈﻧ تﺎﮭﻣﻻا تﺎﻌﺿﺮﻤﻟا ﺧو ﺒ ﺮ ا ﺗ ﮭ ﻢ ﺔﻋﺎﺿﺮﻟﺎﺑ ﺔﯿﻌﯿﺒﻄﻟا ﺔﯾﺮﺼﺤﻟا ﻲﻓ تاﺮﺘﻓ ﻌﻣ ﯿ ﻨ ﺔ ﺪﻌﺑ ﻻﻮﻟا ةد ( ﻲﻓ مﻮﯿﻟا ﻊﺑﺎﺴﻟا ﻲﻓو ﺮﮭﺷﻻا ٢،٤ ﺪﻌﺑ ةدﻻﻮﻟا .) ﻦﻣو ﻊﻗﻮﺘﻤﻟا نأ تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺬھ ه ﺔﺳارﺪﻟا ﺪﻋﺎﺴﯿﺳ زو ا ر ة ﺔﺤﺼﻟا ﻲﻓ ﺔﻨﻄﻠﺳ ﻤﻋ ﺎ ن ﻦﯿﺴﺤﺘﻟ ﺔﯾﺎﻋﺮﻟا ﺔﻣﺪﻘﻤﻟا ﮭﻣﻸﻟ تﺎ تﺎﻌﺿﺮﻤﻟا ﻦﻣ لﻼﺧ ﻓﺮﻌﻣ ﺔ تاﺮﺒﺧ تﺎﮭﻣﻻا ﻲﻓ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا . . اذﺎﻤﻟ ﻢﺗ ﺘﺧا ﯿ يرﺎ ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ؟ﺚﺤﺒﻟا ﺪﻘﻟ ﻢﺗ ﺘﺧا ﯿ كرﺎ ﻚﻧﻷ ﺖﺒﺠﻧا ﻔط ﻚﻠ / ﻔط ﻠ ﻚﺘ ﻲﻓ ﺴﻣ ﺘ ﻰﻔﺸ ﺤﺻ ﺎ ر ﺔﻈﻓﺎﺤﻤﺑ ﻤﺷ ﺎ ل ،ﺔﻨطﺎﺒﻟا ﺪﺑو تأ عﺎﺿرا ﻔط ﻚﻠ / ﻔط ﻠ ﻚﺘ ﺿر ﺎ ﻋ ﺔ ﺒط ﯿ ﻌ ﯿ ﺔ ﻲﻓ ﻰﻔﺸﺘﺴﻤﻟا . او ﺎﻀﯾ ﻞﻤﺘﺷاو ﻌﻣ ﺎ ﯾ ﺮﯿ ﺬھ ه ﺔﺳارﺪﻟا ﻚﯿﻓ . . ﺎﻣ يﺬﻟا ﻦﻜﻤﯾ نأ ﺐﻠﻄﯾ ﻲﻨﻣ نأ ﻞﻌﻓأ اذإ ﺎﺷ ﺖﻛر ﻲﻓ ؟ﺚﺤﺒﻟا اذإ او ﺖﻘﻓ ﻰﻠﻋ رﺎﺸﻤﻟا ﺔﻛ ﻲﻓ ﺬھ ه ،ﺔﺳارﺪﻟا فﻮﺳ ﺐﻠﻄﯾ ﻚﻨﻣ ﻊﯿﻗﻮﺘﻟا ﻰﻠﻋ ﺘﺨﺴﻧ ﻦﯿ ﻦﻣ ةرﺎﻤﺘﺳا ،ﺔﻘﻓاﻮﻤﻟا ةرﺎﻤﺘﺳا ةﺪﺣاو ﻚﻟ ةرﺎﻤﺘﺳﻻاو ﺔﯿﻧﺎﺜﻟا ﺘﺳ ﺒ ﻰﻘ ﻊﻣ ﺚﺣﺎﺒﻟا . ﺚﺣﺎﺒﻟا فﻮﺳ ﻞﺼﺘﯾ ﻚﺑ ﺗﻼﻟ ﻔ قﺎ ﻰﻠﻋ ﻣز نﺎ ﻜﻣو نﺎ ﺮﺟﻹ ا ء تﻼﺑﺎﻘﻤﻟا . ﺬھو ه تﻼﺑﺎﻘﻤﻟا ﺘﺳ نﻮﻜ ﻰﻠﻋ تاﺮﺘﻓ ﻌﻣ ﯿ ﻨ ﺔ ﺧﻹ ﺒ ﺎ ر ﺚﺣﺎﺒﻟا ﻦﻋ ﻚﺗﺮﺒﺧ ﻲﻓ ﺔﻋﺎﺿﺮﻟا لﻼﺧ ﺮﮭﺷﻻا ﺔﻌﺑرﻻا ﻰﻟوﻻا ﻦﻣ ةدﻻﻮﻟا . فﻮﺳو ﻢﺘﺗ ﺬھ ه تﻼﺑﺎﻘﻤﻟا ﺎﻣإ ﻲﻓ تادﺎﯿﻌﻟا ﺔﯿﺤﺼﻟا وأ ﻲﻓ ﻚﻟﺰﻨﻣ . او ﻟ ﺒ ﺚﺣﺎ فﻮﺳ ﯿﺳ ﻞﺼﺘ ﻚﺑ ﺗﻼﻟ ﻔ قﺎ ﻰﻠﻋ ﺖﻗو ﻜﻣو نﺎ تﻼﺑﺎﻘﻤﻟا ﻰﺘﺣ ﻻ ﺐﺒﺴﻧ ﻚﻟ جﺎﻋزﻹا . ﺳو ﯿ ﺘ ﻢ ﻞﯿﺠﺴﺗ تﻼﺑﺎﻘﻤﻟا ﻲﻓ ﻞﺠﺴﻤﻟا ﻰﺘﺣ ﻻ ﺪﻘﻔﯾ ﺚﺣﺎﺒﻟا يا ﻦﻣ ﻠﻌﺗ ﯿ ﻘ ﺎ ﻢﻜﺗ . وﻼﻋو ة ﻋ ﻰﻠ ،ﻚﻟذ ﻦﻤﻓ ﻦﻜﻤﻤﻟا نأ ﻢﺘﯾ ﺮﻣ ا ﻗ ﺒ ﺘ ﻜ ﻢ ﻲﻓ تﺎﺴﺳﺆﻤﻟا ﺔﯿﺤﺼﻟا ( ﻲﻓ ﻨﺟ حﺎ ةدﻻﻮﻟا وأ ﻲﻓ ﯿﻋ ﺎ د تا ﺔﻣﻮﻣﻻا او ﺔﻟﻮﻔﻄﻟ ءﺎﻨﺛأ ﺔﺳارﺪﻟا . . اذﺎﻣ ثﺪﺤﯿﺳ تﺎﻧﺎﯿﺒﻠﻟ ﻲﺘﻟا ﻢﺗ ﻤﺟ ﮭﻌ ﺎ ؟ ﻌﻤ ﯿﺳ ﺘ ﻢ ﺦﺴﻧ ﻤﺟ ﯿ ﻊ تﻼﯿﺠﺴﺗ ﺔﻠﺑﺎﻘﻤﻟا ﻦﻣ ﻞﺒﻗ ﺚﺣﺎﺒﻟا فﻮﺳو نﻮﻜﯾ ﻞﻜﻟ ﺸﻣ ﺎ كر ﻮھ ﯾ ﮫ ﻔﺸﻣ ﺮ ة . ﯿﺳ ﺘ ﻢ ﻦﯾﺰﺨﺗ ﻤﺟ ﯿ ﻊ تﺎﻧﺎﯿﺒﻟا ﺸﺑ ﻞﻜ ﻦﻣآ ﺳو ﯿ ﺘ ﻢ ﻦﯾﺰﺨﺗ تﺎﻧﺎﯿﺒﻟا ﻟﻹا ﻧوﺮﺘﻜ ﺔﯿ ﻰﻠﻋ ﮭﺟ ﺎ ز ﻤﻛ ﺒ ﺮﺗﻮﯿ ﻲﻤﺤﻣ ﺔﻤﻠﻜﺑ روﺮﻣ . ﺔﯿﻔﯿﻛ ظﺎﻔﺤﻟا ﻰﻠﻋ ﺔﯾﺮﺴﻟا ﻲﻓ ؟ﺚﺤﺒﻟا ﺪﻌﺑ ﻊﻤﺟ تﺎﻣﻮﻠﻌﻤﻟا ﻞﻠﺤﺘﺳ ﻞﻜﺸﺑ ﻻ ﺮﮭﻈﺗ ﻮھ ﯾ ﮫ كرﺎﺸﻤﻟا ﺚﯿﺤﺑ ﺮﮭﻈﺘﺳ ﯾﺮﻄﺑ ﻘ ﮫ ﻮﮭﺠﻣ ﻟ ﺔ ( ﺰﻣﺮﺑ كرﺎﺸﻤﻟا .) ﯿﺳ ﺘ ﻢ ﻦﯾﺰﺨﺗ تارﺎﻤﺘﺳا ﺔﻘﻓاﻮﻤﻟا ﻲﻓ ﺰﺧ ا ﻧ ﺔ ﻠﻣ تﺎﻔ ﮫﺼﺼﺨﻣ ﻐﻣو ﻠ ﻘ ﮫ ﺳو ﯿ ﺘ ﻢ ﻦﯾﺰﺨﺗ ﺎﮭﻨﯾوﺪﺗ ﻰﻠﻋ ﮭﺟ ﺎ ز ﻤﻛ ﺒ ﺮﺗﻮﯿ ﻲﻤﺤﻣ ﺔﻤﻠﻜﺑ روﺮﻣ . ﻦﻟ ﺮﮭﻈﺗ ءﺎﻤﺳأ ﻦﯿﻛرﺎﺸﻤﻟا ﺗو ﻔ ﻢﮭﻠﯿﺻﺎ ﻲﻓ يأ ﻦﻣ ﻖﺋﺎﺛﻮﻟا ،ﺔﻋﻮﺒﻄﻤﻟا ﯿﺳ ﺘ ﻢ ضﺮﻋ يأ تﺎﺳﺎﺒﺘﻗا ﻦﻣ ﺮﯿﻏ ﮭظ رﻮ يأ ﻦﻣ ﻌﻣ ﻠ ﻣﻮ تﺎ ﻦﯿﻛرﺎﺸﻤﻟا . ﯿﺳ ﺘ ﻢ ﺘﺣﻻا ﻔ ظﺎ ﺎﻜﺑ ﺔﻓ تﺎﻧﺎﯿﺒﻟا ةﺪﻤﻟ ١٠ ﻮﻨﺳ تا ﻲﻠﻋ ﺐﺴﺣ اﻮﻗ ﻧ ﻦﯿ او ﮫﻤﻈﻧ ﺎﺟ ﺔﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ . ﯿﺳ ﻜ نﻮ ﻂﻘﻓ يﺪﻟ ﻓﺮﺸﻣ ﯿ ﻦ ﺚﺣﺎﺒﻟا ﺔﯿﺻﺎﺨﻟا لﻮﺻﻮﻠﻟ ﻲﻟا تﺎﻧﺎﯿﺒﻟا . . اذﺎﻣ ثﺪﺤﯾ اذإ ﺖﻨﻛ ﻻ ﺪﯾﺮﺗ نأ ﺎﺸﺗ كر وأ اذإ ﺖﻤﻗ ﺮﯿﯿﻐﺘﺑ أر ؟ﻲﯾأ

396 ﺮﻣﻷا كوﺮﺘﻣ ﻚﻟ رﺮﻘﺘﻟ ﺎﻣ اذإ ﺖﻨﻛ دﻮﺗ ﺔﻛرﺎﺸﻤﻟا مأ ﻻ . ﻚﻟﺬﻟ اذإ ﺎﻣ ترﺮﻗ نأ ﺬﺧﺄﺗ رود ﻲﻓ ﺚﺤﺒﻟا ﺘﺳ ﻰﻄﻌ رو ﻗ ﺔ ﺔﻘﻓاﻮﻤﻟا ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ﺚﺤﺒﻟا ﺳو ﯿ ﻄ ﺐﻠ ﻚﻨﻣ ﻊﯿﻗﻮﺘﻟا ﻰﻠﻋ ةرﺎﻤﺘﺳﻻا . اذإ ترﺮﻗ ﺔﻛرﺎﺸﻤﻟا ﺖﻧﺂﻓ ﺮﺣ ﻲﻓ بﺎﺤﺴﻧﻻا ﻲﻓ يأ ﻠﺣﺮﻣ ﮫ ﻦﻣ ﺮﻣ ا ﻞﺣ ﺚﺤﺒﻟا نود ءاﺪﺑإ يأ ﺐﺒﺳ ﻦﻣ ﺒﺳﻷا بﺎ . ﻞھ ﺪﺟﻮﯾ ﻊﻓد ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ؟ﺚﺤﺒﻟا ﻻ ﺪﺟﻮﯾ يأ ﻊﻓد ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ﺚﺤﺒﻟا ﺎﻣ ﻲھ ةﺪﻣ ؟ﺚﺤﺒﻟا ﯿﺳ ﺐﻠﻄﺘ ﺚﺤﺒﻟا هﺪﻣ ﻻ ﻞﻘﺗ ﻦﻋ ثﻼﺛ ﻮﻨﺳ تا ﻦﻜﻟو ﺐﻠﻄﯿﺳ ﻚﻨﻣ ﺎﺸﻤﻟا ﺔﻛر ﻲﻓ ﺔﻠﺑﺎﻘﻤﻟا هﺪﻤﻟ ١ ﺔﻋﺎﺳ . . ﻦﯾا ﯿﺳ ﺘ ﻢ ءاﺮﺟإ ؟ثﻮﺤﺒﻟا ﺘﺳ ﺘ ﻢ ﺔﻠﺑﺎﻘﻤﻟا ﻲﻓ ﺰﻛﺮﻤﻟا ﻲﺤﺼﻟا ﺔﻌﺑﺎﺘﻟا ﺔﯾﻻﻮﻟ ﻲﺘﻟا ﻦﻜﺴﺗ ﺎﮭﺑ ﻲﻓ ﺖﻗﻮﻟا او ﻟ مﻮﯿ او نﺎﻜﻤﻟ يﺬﻟا دﺪﺤﺘﺳ ه . . ﻞھ ﯿﺳ ﺘ ﻢ ﺮﺸﻧ ﺞﺋﺎﺘﻧ ؟ثﺎﺤﺑﻷا ﻞﻣﺄﻧ نأ ﺮﺸﻨﺗ ﺞﺋﺎﺘﻨﻟا ﻲﻓ تﻼﺠﻤﻟا ﺔﯿﻀﯾﺮﻤﺘﻟا او ﺔﯿﺒﻄﻟ او تﻻﺎﺠﻤﻟ ﺔﯿﺤﺼﻟا ىﺮﺧﻷا ﺤﻤﻟا ﺔﯿﻠ او ﻟوﺪﻟ ﺔﯿ . ﺑو ﺔﻓﺎﺿﻹﺎ ﻰﻟإ ،ﻚﻟذ ﻞﻣﺄﻧ ﺎﻀﯾا نأ مﺪﻘﺗ ﺞﺋﺎﺘﻨﻟا تاﺮﻤﺗﺆﻤﻟا ﺔﯿﻀﯾﺮﻤﺘﻟا او ﺔﯿﺒﻄﻟ او تﻻﺎﺠﻤﻟ ﺔﯿﺤﺼﻟا ىﺮﺧﻷا ﺔﯿﻠﺤﻤﻟا او ﻟوﺪﻟ ﺔﯿ . اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ لﻮﺼﺤﻟا ﻰﻠﻋ ﺔﺨﺴﻧ ﻦﻣ تارﻮﺸﻨﻤﻟا ﻨﺳ نﻮﻜ ﻌﺳ ﺪ ا ء ﻞﺳﺮﻨﻟ ﻚﻟ ﮫﺨﺴﻧ ﻦﻣ ﻦﯾا ﻞﺼﺣ ﺮﺸﻣ عو ﺚﺤﺒﻟا ﻰﻠﻋ ؟ﺔﻘﻓاﻮﻤﻟا ﺪﻘﻟ ﺖﻤﺗ ﺮﻣ ا ﮫﻌﺟ ﺒﻟا ﺚﺤ هدﺎﻤﺘﻋاو ﻦﻣ ﻞﺒﻗ ﺔﻨﺠﻟ ﻗﻼﺧﻷا ﯿ تﺎ ﻦﻣ ﺎﺟ ﺔﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ ﻦﻣو ﻞﺒﻗ ﺔﻨﺠﻟ ﻗﻼﺧأ ﯿ تﺎ ثﻮﺤﺒﻟا ﻦﻣ زو ا ر ة ﺔﺤﺼﻟا ﻨﻄﻠﺴﺑ ﺔ ﻤﻋ ﺎ ن . اذﺎﻣ ﻮﻟ ثﺪﺣ ﻄﺧ ﺄ ؟ﺎﻣ ﻻ ﻊﻗﻮﺘﻧ ثوﺪﺤﺑ يا ﺮﻄﺧ وا ﻄﺧ ﺎ ﺒﻣ ﺮﺷﺎ ﻚﻟ ﻲﻓ ﺬھ ه ﺔﺳارﺪﻟا . نﺎﻓ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﺖﻧﺄﻓأ ﺖﺴﻟ ﺖﺤﺗ يأ ماﺰﺘﻟا ﻲﻀﻤﻠﻟ ﺎﻣﺪﻗ ﻼﻓ ﺐﺠﯾ ﻠﻋ ﻚﯿ ﻋإ ﺎﻄ ء يأ ﺐﺒﺳ ﻲﻓ ﺎﺣ ﻟ ﮫ ﺪﻋ م ﺔﻛرﺎﺸﻤﻟا . اذإ نﺎﻛ ﻨھ كﺎ ﺎﻣ ﻚﺠﻋﺰﯾ وا ﺮﯿﺜﯾ ﻚﻟؤﺎﺴﺗ ﺔﺳارﺪﻟﺎﺑ ﻲﺟﺮﯾ لﺎﺼﺗﻻا ﺎﯿﻧوﺮﺘﻜﻟا ﻰﻠﻋ ﻟا ﯾﺮﺒ ﺪ ﺘﻟا ﺎ ﻲﻟ : [email protected]

اذﺎﻣ ﻮﻟ ﺖﻨﻛ ﺐﻏرأ ﻲﻓ ﻢﯾﺪﻘﺗ ﻜﺷ ؟ىﻮﻜ ﻜﺷ ﺎ ىو ﺔﻄﯿﺴﺑ اذإ نﺎﻛ ﻚﯾﺪﻟ ىﻮﻜﺷ ﺔﻄﯿﺴﺑ ﻛو ﺖﻨ ﺔﺟﺎﺤﺑ ﻰﻟإ لﺎﺼﺗﻻا ﺚﺣﺎﺒﻟﺎﺑ ﻲﻓ مﺎﻘﻤﻟا لوﻷا وا ﻲﻠﻋ فﺮﺸﻣ ﺚﺣﺎﺒﻟا Professor Dame Tina Lavender ﺪﯾﺮﺒﻟا ﻟﻹا ﻲﻧوﺮﺘﻜ :[email protected] ﻗر ﻢ ﻒﺗﺎﮭﻟا : ٠٠٤٤١٦١٣٠٦٧٧٤٤ ىوﺎﻜﺸﻟا ﺔﯿﻤﺳﺮﻟا اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ ﻢﯾﺪﻘﺗ ىﻮﻜﺷ ﻤﺳر ﯿ ﺔ وأ اذإ ﺖﻨﻛ ﺮﯿﻏ ضار ﻦﻋ ﺎﺠﺘﺳا ﺔﺑ ﺐﺠﯾ ﻞﺻاﻮﺘﻟا ﻲﻓ مﺎﻘﻤﻟا لوﻻا ﻊﻣ ﺚﺣﺎﺒﻟا ﻢﺛ ءﺎﺟﺮﻟا لﺎﺼﺗﻻا ﻢﺴﻘﺑ ثﻮﺤﺒﻟا ﺪﻣو ﺮﯾ ،ﺔھاﺰﻨﻟا ﻜﻣ ﺐﺘ ثﻮﺤﺒﻟا : Christie Building, University of Manchester, Oxford Road, Manchester, M13 9PL, [email protected] 0161 275 2674 or 275 2046 اذﺎﻣ ﻞﻌﻓأ ؟نﻵا اذإ نﺎﻛ ﻚﯾﺪﻟ يأ ﺘﺳا رﺎﺴﻔ لﻮﺣ ﺔﺳارﺪﻟا وأ اذإ ﺖﻨﻛ ﺐﻏار ﺔﻛرﺎﺸﻤﻟﺎﺑ ءﺎﺟﺮﻟا لﺎﺼﺗﻻا ﺚﺣﺎﺒﻟﺎﺑ . . ﻻ ددﺮﺘﺗ ﻲﻓ ﻨﻣ ﺎ ﺔﺸﻗ ﺬھ ه تﺎﻣﻮﻠﻌﻤﻟا ﻊﻣ ﻦﯾﺮﺧﻻا ( ﻞﺜﻣ ﺎﻋ ﺋ ﻠ ﻚﺘ وأ ﺒط ﯿ ﻚﺒ ) ﻞﺒﻗ نأ رﺮﻘﺗ ﺎﻣ اذإ ﺐﻏﺮﺗ كاﺮﺘﺷﻻﺎﺑ مأ ﻻ . . ﻚﻨﻜﻤﯾ ﺎﻀﯾأ لﺎﺼﺗﻻا ﻖﯾﺮﻔﺑ ثﺎﺤﺑﻻا ﺒﻣ ةﺮﺷﺎ ( ﻞﯿﺻﺎﻔﺘﻟا هﻼﻋأ ) اذإ نﺎﻛ ﻨھ كﺎ ﻲﺷ ء ﺮﯿﻏ ﺢﺿاو . اذإ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺬھ ه ،ﺔﺳارﺪﻟا فﻮﺳ ﻞﺼﺘﻧ ﻚﺑ ﺐﺗﺮﻨﻟ نﺎﻜﻤﻟا او نﺎﻣﺰﻟ ﺐﺳﺎﻨﻤﻟا ﻚﻟ . ﻊﻤﺟ تﺎﻧﺎﯿﺒﻟا فﻮﺳ نﻮﻜﯾ ﻲﻓ تادﺎﯿﻌﻟا ﺔﯿﺤﺼﻟا وأ ﻲﻓ ﻚﻟﺰﻨﻣ .

ﺮﻜﺷ ا ﺧﻷ ﺬ ﺖﻗﻮﻟا ﻲﻓﺎﻜﻟا ةءاﺮﻘﻟ ﺬھ ه تﺎﻣﻮﻠﻌﻤﻟا

ﺖﻤﺗ ﺔﻘﻓاﻮﻤﻟا ﻠﻋ ﻰ عوﺮﺸﻤﻟا ﻦﻣ ﻞﺒﻗ ﮫﻨﺠﻟ ﻗﻼﺧﻻا ﯿ تﺎ ﺎﺠﺑ ﮫﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ [١٦٣٤٦]

397 Appendix 19: PIS for Family Members/ Interview (Arabic)

ثﺪﺤﺘﻟا ﻊﻣ تﺎﮭﻣﻻا تﺎﯿﻧﺎﻤﻌﻟا ﻦﻋ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا راﺪﺻﻹا لوﻷا ﺎﻣ ﻮﯾ ٢٠١٦ جذﻮﻤﻧ ﻌﻣ تﺎﻣﻮﻠ ﻦﯿﻛرﺎﺸﻤﻠﻟ - ﺔﻠﺋﺎﻌﻟ تﺎﮭﻣﻷا ﺪﻌﺑ ةدﻻﻮﻟا

فﻮﺳ ﻢﺘﯾ ﻮﻋد ﻚﺗ ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ رد ﺔﺳا فﺎﺸﻜﺘﺳاو تاﺮﺒﺨﻟا ءارﻵاو ﺎﻌﻟ تﻼﺋ ءﺎﺴﻨﻟا تﺎﯿﻧﺎﻤﻌﻟا ﻲﺗﻻا ﻦﻌﺿﺮﯾ . دواو نا ثﺪﺤﺗا ﻢﻜﯿﻟا ةﺮﻣ ةﺪﺣاو لﻼﺧ ةﺪﻣ ﺬھ ه ﺔﺳارﺪﻟا . ﻰﺟﺮﯾ اﺮﻗ ةء تﺎﻣﻮﻠﻌﻤﻟا ﺔﯿﻟﺎﺘﻟا ﻦﻋ ﺔﺳارﺪﻟا ﻨﻌﺑ ﺎ ،ﺔﯾ ﻻو ددﺮﺘﺗ ﻲﻓ حﺮط يا ﺆﺳ ا ل وأ ﻨﻣ ﺎ ﺔﺸﻗ يأ ﻌﻣ ﻠ ﺔﻣﻮ ﻦﻋ ﺔﺳارﺪﻟا . ﻤﻛ ﺎ ﻚﻨﻜﻤﯾ نأ ﺶﻗﺎﻨﺗ ﺤﻣ ﺘ ىﻮ ﺔﺳارﺪﻟا ﻊﻣ داﺮﻓأ ﻚﺗﺮﺳأ رﺮﻘﺘﻟ ﺎﻣ اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺔﺳارﺪﻟا . . ﻢﻛﺮﻜﺷأ ﻰﻠﻋ ﻗو ﻢﻜﺘ ةءاﺮﻘﻟ رو ﻗ ﮫ تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ يﺮﺠﯿﺳ ﺤﺒﻟا ﺚ؟ ﺎط ﻟ ﺒ ﺔ هارﻮﺘﻛﺪﻟا ﻟز ﺔﺨﯿ ،ﻲﻗوزﺮﻤﻟا ﺔﻠﺻﺎﺣ ﻰﻠﻋ ﺑد مﻮﻠ ﺾﯾﺮﻤﺗ ﺎﻋ م ١٩٩٩، ﺎﻜﺑ سﻮﯾرﻮﻟ ﺾﯾﺮﻤﺗ ﺎﻋ م ٢٠٠٢، ﻣو ﺘﺴﺟﺎ ﺮﯿ ﻲﻓ تﺎﺳرﺎﻤﻤﻟا ﺔﯿﻨﮭﻤﻟا ﺎﻋ م ٢٠٠٧ . ﺎﺣ ﻟ ﯿ ﺎ ﺚﺣﺎﺒﻟا سرﺪﻣ ﺾﯾﺮﻤﺗ ﻲﻓ ﺪﮭﻌﻣ ﻤﺷ ﺎ ل ﺔﻨطﺎﺒﻟا ﺾﯾﺮﻤﺘﻠﻟ . ﺎﻣ ﻮھ ضﺮﻐﻟا ﻦﻣ ﺬھ ه ؟ﺔﺳارﺪﻟا فﺪﮭﺗ ﺬھ ه ﺔﺳارﺪﻟا ﻰﻟا ﺬﺧأ ءارآ ﮭﺟوو تﺎ ﺮﻈﻧ ﻻا ﮭﻣ تﺎ تﺎﻌﺿﺮﻤﻟا ﺧو ﺒ ﺮ ا ﺗ ﮭ ﻢ ﺔﻋﺎﺿﺮﻟﺎﺑ ﺔﯿﻌﯿﺒﻄﻟا ﺔﯾﺮﺼﺤﻟا ﻲﻓ تاﺮﺘﻓ ﻌﻣ ﯿ ﻨ ﺔ ﺪﻌﺑ ةدﻻﻮﻟا ﻛو نﺎ ﻦﻣ ﻢﮭﻤﻟا لﺎﻤﺷا ﻮﻋ ا ﺋ ﻞ تﺎﮭﻣﻻا ﻲﻓ ﺔﺳارﺪﻟا ﻢﮭﻔﻟ ﻌﺟو تﺎ ﻢھﺮﻈﻧ ﻦﻋ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا . ﻦﻣو ﻊﻗﻮﺘﻤﻟا نأ تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺬھ ه ﺔﺳارﺪﻟا ﺪﻋﺎﺴﯿﺳ زو ا ر ة ﺔﺤﺼﻟا ﻲﻓ ﺔﻨﻄﻠﺳ ﻤﻋ ﺎ ن ﻦﯿﺴﺤﺘﻟ ﺔﯾﺎﻋﺮﻟا ﺔﻣﺪﻘﻤﻟا ﮭﻣﻸﻟ تﺎ تﺎﻌﺿﺮﻤﻟا ﻦﻣ لﻼﺧ ﻓﺮﻌﻣ ﺔ تاﺮﺒﺧ تﺎﮭﻣﻻا ﻲﻓ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا . . ﻟ اذﺎﻤ ﻢﺗ ﺘﺧا ﯿ رﺎ ي ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ﺚﺤﺒﻟا ؟ ﺪﻘﻟ ﻢﺗ ﺘﺧا ﯿ كرﺎ ﻚﻧﻷ ﺪﺣأ داﺮﻓأ ةﺮﺳا تﺎﮭﻣﻻا ﻲﺗﻼﻟا ﻦﻌﺿﺮﯾ . . ﺎﻣ يﺬﻟا ﻦﻜﻤﯾ نأ ﯾ ﺐﻠﻄ ﻲﻨﻣ نأ ﻞﻌﻓأ اذإ ﺎﺷ ﻛر ﺖ ﻲﻓ ﺚﺤﺒﻟا ؟ اذإ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺬھ ه ﺔﺳارﺪﻟا ، فﻮﺳ ﺐﻠﻄﯾ ﻚﻨﻣ ﻊﯿﻗﻮﺘﻟا ﻰﻠﻋ ﺘﺨﺴﻧ ﻦﯿ ﻦﻣ ةرﺎﻤﺘﺳا ،ﺔﻘﻓاﻮﻤﻟا ةرﺎﻤﺘﺳا ةﺪﺣاو ﻚﻟ ةرﺎﻤﺘﺳﻻاو ﺔﯿﻧﺎﺜﻟا ﺘﺳ ﺒ ﻰﻘ ﻊﻣ ﺚﺣﺎﺒﻟا . ﺚﺣﺎﺒﻟا فﻮﺳ ﻞﺼﺘﯾ ﻚﺑ ﺗﻼﻟ ﻔ قﺎ ﻰﻠﻋ ﻣز نﺎ ﻜﻣو نﺎ ﺮﺟﻹ ا ء تﻼﺑﺎﻘﻤﻟا . ﺬھو ه ﺔﻠﺑﺎﻘﻤﻟا ﺘﺳ نﻮﻜ ةﺮﻣ ةﺪﺣاو لﻼﺧ ةﺮﺘﻓ ﺔﺳارﺪﻟا . فﻮﺳو ﻢﺘﺗ ﺬھ ه ﺔﻠﺑﺎﻘﻤﻟا ﻲﻓ ﻚﻟﺰﻨﻣ . او ﻟ ﺒ ﺚﺣﺎ فﻮﺳ ﯿﺳ ﻞﺼﺘ ﻚﺑ ﺗﻼﻟ ﻔ قﺎ ﻰﻠﻋ ﺖﻗو ﻜﻣو نﺎ تﻼﺑﺎﻘﻤﻟا ﻰﺘﺣ ﻻ ﺐﺒﺴﻧ ﻚﻟ جﺎﻋزﻹا . ﺳو ﯿ ﺘ ﻢ ﻞﯿﺠﺴﺗ ﺔﻠﺑﺎﻘﻤﻟا ﻲﻓ ﻞﺠﺴﻤﻟا ﻰﺘﺣ ﻻ ﺪﻘﻔﯾ ﺚﺣﺎﺒﻟا يا ﻦﻣ ﻠﻌﺗ ﯿ ﻘ ﺎ ﻢﻜﺗ . اذﺎﻣ ﺳ ثﺪﺤﯿ تﺎﻧﺎﯿﺒﻠﻟ ﻲﺘﻟا ﻢﺗ ﻤﺟ ﮭﻌ ﺎ ؟ ﻌﻤ ﯿﺳ ﺘ ﻢ ﺦﺴﻧ ﻤﺟ ﯿ ﻊ تﻼﯿﺠﺴﺗ ﻟا ﻘﻤ ﺎ ﺑ ﺔﻠ ﻦﻣ ﻞﺒﻗ ﺚﺣﺎﺒﻟا فﻮﺳو نﻮﻜﯾ ﻞﻜﻟ ﺸﻣ ﺎ كر ﻮھ ﯾ ﮫ ﻔﺸﻣ ﺮ ة . ﯿﺳ ﺘ ﻢ ﻦﯾﺰﺨﺗ ﻤﺟ ﯿ ﻊ تﺎﻧﺎﯿﺒﻟا ﻞﻜﺸﺑ ﻦﻣآ ﺳو ﯿ ﺘ ﻢ ﻦﯾﺰﺨﺗ تﺎﻧﺎﯿﺒﻟا ﻟﻹا ﻧوﺮﺘﻜ ﺔﯿ ﻰﻠﻋ ﮭﺟ ﺎ ز ﻤﻛ ﺒ ﺮﺗﻮﯿ ﻲﻤﺤﻣ ﺔﻤﻠﻜﺑ روﺮﻣ . ﺔﯿﻔﯿﻛ ظﺎﻔﺤﻟا ﻰﻠﻋ ﺔﯾﺮﺴﻟا ﻲﻓ ﺚﺤﺒﻟا ؟ ﺪﻌﺑ ﻊﻤﺟ تﺎﻣﻮﻠﻌﻤﻟا ﻞﻠﺤﺘﺳ ﻞﻜﺸﺑ ﻻ ﺮﮭﻈﺗ ﻮھ ﯾ ﮫ كرﺎﺸﻤﻟا ﺚﯿﺤﺑ ﺮﮭﻈﺘﺳ ﯾﺮﻄﺑ ﻘ ﮫ ﻮﮭﺠﻣ ﻟ ﺔ ( ﺰﻣﺮﺑ كرﺎﺸﻤﻟا .) ﯿﺳ ﺘ ﻢ ﻦﯾﺰﺨﺗ تارﺎﻤﺘﺳا ﺔﻘﻓاﻮﻤﻟا ﻲﻓ ﺰﺧ ا ﻧ ﺔ ﻠﻣ تﺎﻔ ﮫﺼﺼﺨﻣ ﻐﻣو ﻠ ﻘ ﮫ ﺳو ﯿ ﺘ ﻢ ﻦﯾﺰﺨﺗ ﻨﯾوﺪﺗ ﺎﮭ ﻰﻠﻋ ﮭﺟ ﺎ ز ﻤﻛ ﺒ ﺮﺗﻮﯿ ﻲﻤﺤﻣ ﺔﻤﻠﻜﺑ روﺮﻣ . ﻦﻟ ﺮﮭﻈﺗ ءﺎﻤﺳأ ﻦﯿﻛرﺎﺸﻤﻟا ﺗو ﻔ ﻠﯿﺻﺎ ﻢﮭ ﻲﻓ يأ ﻦﻣ ﻟا ﺛﻮ ﺎ ﻖﺋ ﻟا ﻄﻤ ﺒ ﺔﻋﻮ ، ﯿﺳ ﺘ ﻢ ضﺮﻋ يأ تﺎﺳﺎﺒﺘﻗا ﻦﻣ ﺮﯿﻏ ﮭظ رﻮ يأ ﻦﻣ ﻌﻣ ﻠ ﻣﻮ تﺎ ﻦﯿﻛرﺎﺸﻤﻟا . ﯿﺳ ﺘ ﻢ ﺘﺣﻻا ﻔ ظﺎ ﺑ ﺎﻜ ﺔﻓ تﺎﻧﺎﯿﺒﻟا ةﺪﻤﻟ ١٠ ﻮﻨﺳ تا ﻲﻠﻋ ﺐﺴﺣ اﻮﻗ ﻧ ﻦﯿ او ﮫﻤﻈﻧ ﺎﺟ ﺔﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ . ﯿﺳ نﻮﻜ ﻂﻘﻓ يﺪﻟ ﻓﺮﺸﻣ ﯿ ﻦ ﺚﺣﺎﺒﻟا ﺔﯿﺻﺎﺨﻟا لﻮﺻﻮﻠﻟ ﻲﻟا تﺎﻧﺎﯿﺒﻟا . اذﺎﻣ ثﺪﺤﯾ اذإ ﺖﻨﻛ ﻻ ﺪﯾﺮﺗ نأ ﺎﺸﺗ كر وأ اذإ ﺖﻤﻗ ﺮﯿﯿﻐﺘﺑ أر ؟ﻲﯾأ ﺮﻣﻷا كوﺮﺘﻣ ﻚﻟ رﺮﻘﺘﻟ ﺎﻣ اذإ ﻛ ﺖﻨ دﻮﺗ ﺔﻛرﺎﺸﻤﻟا أم ﻻ . ﻚﻟﺬﻟ اذإ ﺎﻣ رﺮﻗ ت نأ ﺗ ﺬﺧﺄ رود ﻲﻓ ﺚﺤﺒﻟا ﺘﺳ ﻰﻄﻌ رو ﻗ ﺔ ﺔﻘﻓاﻮﻤﻟا ﺎﺸﻤﻠﻟ ﺔﻛر ﻲﻓ ﺚﺤﺒﻟا وﺳ ﺐﻠﻄﯿ ﻚﻨﻣ ﻊﯿﻗﻮﺘﻟا ﻰﻠﻋ ﻻا ﺘﺳ ﻤ ةرﺎ . اذإ ترﺮﻗ ﺔﻛرﺎﺸﻤﻟا ﺖﻧﺂﻓ ﺮﺣ ﻲﻓ ﻧﻻا ﺤﺴ ﺎب ﻲﻓ يأ ﻠﺣﺮﻣ ﮫ ﻦﻣ ﺮﻣ ا ﻞﺣ ﺚﺤﺒﻟا نود ءاﺪﺑإ يأ ﺐﺒﺳ ﻦﻣ ﻷا ﺒﺳ بﺎ . ﻞھ ﺪﺟﻮﯾ ﻊﻓد ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ؟ﺚﺤﺒﻟا ﻻ ﺪﺟﻮﯾ يأ ﻊﻓد ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ﺚﺤﺒﻟا . ﺎﻣ ﻲھ ةﺪﻣ ؟ﺚﺤﺒﻟا ﯿﺳ ﺐﻠﻄﺘ ﺚﺤﺒﻟا هﺪﻣ ﻻ ﻞﻘﺗ ﻦﻋ ثﻼﺛ ﺳ تاﻮﻨ ﻦﻜﻟو ﺐﻠﻄﯿﺳ ﻚﻨﻣ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺔﻠﺑﺎﻘﻤﻟا هﺪﻤﻟ حواﺮﺘﺗ ١ ﺔﻋﺎﺳ . .

398 ﻦﯾا ﯿﺳ ﺘ ﻢ ءاﺮﺟإ ؟ثﻮﺤﺒﻟا ﺘﺳ ﺘ ﻢ ﺔﻠﺑﺎﻘﻤﻟا ﻲﻓ ﻚﻟﺰﻨﻣ ﻲﻓ ﺖﻗﻮﻟا او ﻟ مﻮﯿ او نﺎﻜﻤﻟ يﺬﻟا دﺪﺤﺘﺳ ه . . ﻞھ ﯿﺳ ﺘ ﻢ ﺮﺸﻧ ﺞﺋﺎﺘﻧ ؟ثﺎﺤﺑﻷا ﻞﻣﺄﻧ نأ ﺮﺸﻨﺗ ﺞﺋﺎﺘﻨﻟا ﻲﻓ تﻼﺠﻤﻟا ﺔﯿﻀﯾﺮﻤﺘﻟا او ﺔﯿﺒﻄﻟ او تﻻﺎﺠﻤﻟ ﺔﯿﺤﺼﻟا ىﺮﺧﻷا ﺔﯿﻠﺤﻤﻟا او ﻟوﺪﻟ ﺔﯿ . ﺑو ﺔﻓﺎﺿﻹﺎ ﻰﻟإ ،ﻚﻟذ ﻞﻣﺄﻧ ﺎﻀﯾا نأ مﺪﻘﺗ ﺞﺋﺎﺘﻨﻟا تاﺮﻤﺗﺆﻤﻟا ﺔﯿﻀﯾﺮﻤﺘﻟا او ﺔﯿﺒﻄﻟ او تﻻﺎﺠﻤﻟ ﺔﯿﺤﺼﻟا ىﺮﺧﻷا ﺔﯿﻠﺤﻤﻟا او ﻟوﺪﻟ ﺔﯿ . اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ لﻮﺼﺤﻟا ﻰﻠﻋ ﺔﺨﺴﻧ ﻦﻣ تارﻮﺸﻨﻤﻟا ﻨﺳ نﻮﻜ ﻌﺳ ﺪ ا ء ﻞﺳﺮﻨﻟ ﻚﻟ ﮫﺨﺴﻧ ﻦﻣ ﻦﯾا ﻞﺼﺣ ﺮﺸﻣ عو ﺚﺤﺒﻟا ﻰﻠﻋ ؟ﺔﻘﻓاﻮﻤﻟا ﺪﻘﻟ ﺖﻤﺗ ﺮﻣ ا ﻌﺟ ﮫ ﺚﺤﺒﻟا هدﺎﻤﺘﻋاو ﻦﻣ ﻞﺒﻗ ﺔﻨﺠﻟ ﻗﻼﺧﻷا ﯿ تﺎ ﻦﻣ ﺎﺟ ﺔﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ ﻦﻣو ﻞﺒﻗ ﺔﻨﺠﻟ ﻗﻼﺧأ ﯿ تﺎ ثﻮﺤﺒﻟا ﻦﻣ زو ا ر ة ﺔﺤﺼﻟا ﻨﻄﻠﺴﺑ ﺔ ﻤﻋ ﺎ ن . اذﺎﻣ ﻮﻟ ثﺪﺣ ﻄﺧ ﺄ ؟ﺎﻣ ﻻ ﻊﻗﻮﺘﻧ ثوﺪﺤﺑ يا ﺮﻄﺧ وا ﻄﺧ ﺎ ﺒﻣ ﺮﺷﺎ ﻚﻟ ﻲﻓ ﺬھ ه ﺔﺳارﺪﻟا . نﺎﻓ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﺖﻧﺎﻓا ﺖﺴﻟ ﺖﺤﺗ يأ ماﺰﺘﻟا ﻲﻀﻤﻠﻟ ﺎﻣﺪﻗ ﻼﻓ ﺐﺠﯾ ﻠﻋ ﻚﯿ ءﺎﻄﻋإ يأ ﺐﺒﺳ ﻲﻓ ﺎﺣ ﻟ ﮫ ﺪﻋ م ﻛرﺎﺸﻤﻟا ﺔ . اذإ نﺎﻛ ﻨھ كﺎ ﺎﻣ ﻚﺠﻋﺰﯾ وا ﺮﯿﺜﯾ ﻚﻟؤﺎﺴﺗ ﺔﺳارﺪﻟﺎﺑ ﻲﺟﺮﯾ لﺎﺼﺗﻻا ﺎﯿﻧوﺮﺘﻜﻟا ﻰﻠﻋ ﻞﯿﻤﯾﻻا ﻲﻟﺎﺘﻟا : [email protected] اذﺎﻣ ﻮﻟ ﺖﻨﻛ رأ ﺐﻏ ﻲﻓ ﻢﯾﺪﻘﺗ ﻜﺷ ؟ىﻮﻜ ﻜﺷ ﺎ ىو ﺔﻄﯿﺴﺑ اذإ نﺎﻛ ﻚﯾﺪﻟ ىﻮﻜﺷ ﺔﻄﯿﺴﺑ ﻛو ﺖﻨ ﺔﺟﺎﺤﺑ ﻰﻟإ لﺎﺼﺗﻻا ﺑ ﺚﺣﺎﺒﻟﺎ ﻲﻓ مﺎﻘﻤﻟا وﻷا ل وا ﻲﻠﻋ فﺮﺸﻣ ﺚﺣﺎﺒﻟا Professor Dame Tina Lavender ﺪﯾﺮﺒﻟا ﻟﻹا ﻲﻧوﺮﺘﻜ :[email protected] ﻗر ﻢ ﺗﺎﮭﻟا ﻒ : ٠٠٤٤١٦١٣٠٦٧٧٤٤ ىوﺎﻜﺸﻟا ﺔﯿﻤﺳﺮﻟا اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ ﻢﯾﺪﻘﺗ ىﻮﻜﺷ ﻤﺳر ﯿ ﺔ وأ اذإ ﺖﻨﻛ ﺮﯿﻏ ضار ﻦﻋ ﺎﺠﺘﺳا ﺔﺑ ﺐﺠﯾ ﻞﺻاﻮﺘﻟا ﻲﻓ مﺎﻘﻤﻟا لوﻻا ﻊﻣ ﺚﺣﺎﺒﻟا ﻢﺛ ءﺎﺟﺮﻟا لﺎﺼﺗﻻا ﻢﺴﻘﺑ ثﻮﺤﺒﻟا ﺪﻣو ﺮﯾ ،ﺔھاﺰﻨﻟا ﻜﻣ ﺐﺘ ثﻮﺤﺒﻟا : Christie Building, University of Manchester, Oxford Road, Manchester, M13 9PL, [email protected] 0161 275 2674 or 275 2046

اذﺎﻣ ﻞﻌﻓأ ؟نﻵا اذإ نﺎﻛ ﻚﯾﺪﻟ يأ ﺘﺳا رﺎﺴﻔ لﻮﺣ ﺔﺳارﺪﻟا وأ اذإ ﺖﻨﻛ ﺐﻏار ﺔﻛرﺎﺸﻤﻟﺎﺑ ءﺎﺟﺮﻟا لﺎﺼﺗﻻا ﺚﺣﺎﺒﻟﺎﺑ .

ﻻ ددﺮﺘﺗ ﻲﻓ ﻨﻣ ﺎ ﺔﺸﻗ ﺬھ ه تﺎﻣﻮﻠﻌﻤﻟا ﻊﻣ ﻦﯾﺮﺧﻻا ﻞﺒﻗ نأ رﺮﻘﺗ ﺎﻣ اذإ ﺐﻏﺮﺗ كاﺮﺘﺷﻻﺎﺑ مأ ﻻ . ﻚﻨﻜﻤﯾ ﺎﻀﯾأ لﺎﺼﺗﻻا ﻖﯾﺮﻔﺑ ثﺎﺤﺑﻻا ﺒﻣ ةﺮﺷﺎ ( ﻞﯿﺻﺎﻔﺘﻟا هﻼﻋأ ) اذإ نﺎﻛ ﻨھ كﺎ ﻲﺷ ء ﺮﯿﻏ ﺢﺿاو . اذإ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺬھ ه ،ﺔﺳارﺪﻟا فﻮﺳ ﻞﺼﺘﻧ ﻚﺑ ﺐﺗﺮﻨﻟ نﺎﻜﻤﻟا او نﺎﻣﺰﻟ ﺐﺳﺎﻨﻤﻟا ﻚﻟ . ﻊﻤﺟ تﺎﻧﺎﯿﺒﻟا فﻮﺳ نﻮﻜﯾ ﻲﻓ ﻚﻟﺰﻨﻣ .

ﺮﻜﺷ ا ﺧﻷ ﺬ ﺖﻗﻮﻟا ﻲﻓﺎﻜﻟا ةءاﺮﻘﻟ ﺬھ ه تﺎﻣﻮﻠﻌﻤﻟا .

ﺖﻤﺗ ﮫﻘﻓاﻮﻤﻟا ﻠﻋ ﻰ عوﺮﺸﻤﻟا ﻦﻣ ﻞﺒﻗ ﮫﻨﺠﻟ ﻗﻼﺧﻻا ﯿ تﺎ ﺎﺠﺑ ﮫﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ [١٦٣٤٦]

399 Appendix 20: PIS for Postnatal Mothers Observation (Arabic)

ثﺪﺤﺘﻟا ﻊﻣ تﺎﮭﻣﻻا تﺎﯿﻧﺎﻤﻌﻟا ﻦﻋ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا راﺪﺻﻹا لوﻷا ﺎﻣ ﻮﯾ ٢٠١٦ جذﻮﻤﻧ ﻌﻣ تﺎﻣﻮﻠ ﻦﯿﻛرﺎﺸﻤﻠﻟ - ﺔﻈﺣﻼﻣ تﺎﮭﻣﻻا ﺪﻌﺑ ةدﻻﻮﻟا

فﻮﺳ ﻢﺘﯾ ﻮﻋد ﻚﺗ ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ رد ﺔﺳا فﺎﺸﻜﺘﺳاو تاﺮﺒﺨﻟا ءارﻵاو ﻦﻣ ءﺎﺴﻨﻟا تﺎﯿﻧﺎﻤﻌﻟا ﻲﺗﻻا ﻦﻌﺿﺮﯾ . دواو نأ ارأ ﺐﻗ ﯿﻛ ﻔ ﺔﯿ ﻢﻋد ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا ﻲﻓ تﺎﺴﺳﺆﻤﻟا ﺔﯿﺤﺼﻟا ﻲﺘﻟا ﻞﻤﻌﺗ ﻲﻓ تﺎﺴﺳﺆﻤﻟا ﺔﯿﺤﺼﻟا . ﻰﺟﺮﯾ اﺮﻗ ةء تﺎﻣﻮﻠﻌﻤﻟا ﺔﯿﻟﺎﺘﻟا ﻦﻋ ﺔﺳارﺪﻟا ﻨﻌﺑ ﺎ ،ﺔﯾ ﻻو ددﺮﺘﺗ ﻲﻓ حﺮط يا ﺆﺳ ا ل وأ ﻨﻣ ﺎ ﺔﺸﻗ يأ ﻌﻣ ﻠ ﺔﻣﻮ ﻦﻋ ﺔﺳارﺪﻟا . ﻤﻛ ﺎ ﻚﻨﻜﻤﯾ نأ ﺶﻗﺎﻨﺗ ﺤﻣ ﺘ ىﻮ ﺔﺳارﺪﻟا ﻊﻣ داﺮﻓأ ﻚﺗﺮﺳأ رﺮﻘﺘﻟ ﺎﻣ اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺔﺳارﺪﻟا . . ﻢﻛﺮﻜﺷأ ﻰﻠﻋ ﻗو ﻢﻜﺘ ةءاﺮﻘﻟ رو ﻗ ﮫ تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ يﺮﺠﯿﺳ ؟ﺚﺤﺒﻟا ﺎط ﻟ ﺒ ﺔ هارﻮﺘﻛﺪﻟا ﻟز ﺔﺨﯿ ،ﻲﻗوزﺮﻤﻟا ﺔﻠﺻﺎﺣ ﻰﻠﻋ ﺑد مﻮﻠ ﺾﯾﺮﻤﺗ ﺎﻋ م ١٩٩٩، ﺎﻜﺑ سﻮﯾرﻮﻟ ﺾﯾﺮﻤﺗ ﺎﻋ م ٢٠٠٢، ﻣو ﺘﺴﺟﺎ ﺮﯿ ﻲﻓ تﺎﺳرﺎﻤﻤﻟا ﺔﯿﻨﮭﻤﻟا ﺎﻋ م ٢٠٠٧ . ﺎﺣ ﻟ ﯿ ﺎ ﺚﺣﺎﺒﻟا سرﺪﻣ ﺾﯾﺮﻤﺗ ﻲﻓ ﺪﮭﻌﻣ ﻤﺷ ﺎ ل ﺔﻨطﺎﺒﻟا ﺾﯾﺮﻤﺘﻠﻟ . ﺎﻣ ﻮھ ضﺮﻐﻟا ﻦﻣ ﺬھ ه ؟ﺔﺳارﺪﻟا فﺪﮭﺗ ﺬھ ه ﺔﺳارﺪﻟا ﻰﻟا ﺬﺧأ ءارآ ﮭﺟوو تﺎ ﺮﻈﻧ تﺎﮭﻣﻻا تﺎﻌﺿﺮﻤﻟا ﺧو ﺒ ﺮ ا ﺗ ﮭ ﻢ ﺔﻋﺎﺿﺮﻟﺎﺑ ﺔﯿﻌﯿﺒﻄﻟا ﺔﯾﺮﺼﺤﻟا ﻲﻓ تاﺮﺘﻓ ﻌﻣ ﯿ ﻨ ﺔ ﺪﻌﺑ ﻻﻮﻟا ةد . ﻚﻟﺬﻟ نﺎﻛ ﻦﻣ ﻢﮭﻤﻟا ﺔﻈﺣﻼﻣ تﻼﺑﺎﻘﻟا ﻦﻋ ﯿﻛ ﻔ ﺔﯿ ﻢﻋد ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا ﻲﻓ تﺎﺴﺳﺆﻤﻟا ﺔﯿﺤﺼﻟا ﺔﻌﺑﺎﺘﻟا ةرازﻮﻟ ﺔﺤﺼﻟا . ﻦﻣو ﻊﻗﻮﺘﻤﻟا نأ تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺬھ ه ﺔﺳارﺪﻟا ﺪﻋﺎﺴﯿﺳ زو ا ر ة ﺔﺤﺼﻟا ﻲﻓ ﺔﻨﻄﻠﺳ ﻤﻋ ﺎ ن ﻦﯿﺴﺤﺘﻟ ﺔﯾﺎﻋﺮﻟا ﺔﻣﺪﻘﻤﻟا ﮭﻣﻸﻟ تﺎ تﺎﻌﺿﺮﻤﻟا ﻦﻣ لﻼﺧ ﻓﺮﻌﻣ ﺔ تاﺮﺒﺧ تﺎﮭﻣﻻا ﻲﻓ ا ﺔﻋﺎﺿﺮﻟ ﺔﯿﻌﯿﺒﻄﻟا . . اذﺎﻤﻟ ﻢﺗ ﺘﺧا ﯿ يرﺎ ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ؟ﺚﺤﺒﻟا ﺪﻘﻟ ﻢﺗ ﺘﺧا ﯿ كرﺎ ﻚﻧﻷ ما ﺪﻗو ﻌﺿو ﺖ ﻔط ﻚﻠ ﻲﻣﺪﺨﺘﺴﺗو تﺎﻣﺪﺨﻟا ﺔﯿﺤﺼﻟا ﺔﻌﺑﺎﺘﻟا ةرازﻮﻟ ﺔﺤﺼﻟا . . ﺎﻣ يﺬﻟا ﻦﻜﻤﯾ نأ ﺐﻠﻄﯾ ﻲﻨﻣ نأ ﻞﻌﻓأ اذإ ﺎﺷ ﺖﻛر ﻲﻓ ؟ﺚﺤﺒﻟا اذإ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺬھ ه ،ﺔﺳارﺪﻟا فﻮﺳ ﺐﻠﻄﯾ ﻚﻨﻣ ﻊﯿﻗﻮﺘﻟا ﻰﻠﻋ ﺘﺨﺴﻧ ﻦﯿ ﻦﻣ ةرﺎﻤﺘﺳا ،ﺔﻘﻓاﻮﻤﻟا ةرﺎﻤﺘﺳا ةﺪﺣاو ﻚﻟ ةرﺎﻤﺘﺳﻻاو ﺔﯿﻧﺎﺜﻟا ﺘﺳ ﺒ ﻰﻘ ﻊﻣ ﺚﺣﺎﺒﻟا . ﺚﺣﺎﺒﻟا فﻮﺳ ﻞﺼﺘﯾ ﻚﺑ ﺗﻼﻟ ﻔ قﺎ ﻰﻠﻋ ﻣز نﺎ ﻜﻣو نﺎ ﺮﺟﻹ ا ء ﺔﺒﻗاﺮﻤﻟا . . فﻮﺳو ﻦﻤﻀﺘﺗ ﺔﺒﻗاﺮﻤﻟا ٢٠-٣٠ ﺔﻘﯿﻗد . فﻮﺳو ﻢﺘﺗ ﺬھ ه ﺔﺒﻗاﺮﻤﻟا ﻲﻓ تادﺎﯿﻌﻟا ﺔﯿﺤﺼﻟا . او ﻟ ﺒ ﺚﺣﺎ فﻮﺳ ﯿﺳ ﻞﺼﺘ ﻚﺑ ﺗﻼﻟ ﻔ قﺎ ﻰﻠﻋ ﺖﻗو ﻜﻣو نﺎ تﻼﺑﺎﻘﻤﻟا ﻰﺘﺣ ﻻ ﺐﺒﺴﻧ ﻚﻟ جﺎﻋزﻹا .

اذﺎﻣ ثﺪﺤﯿﺳ تﺎﻧﺎﯿﺒﻠﻟ ﻲﺘﻟا ﻢﺗ ﻤﺟ ﮭﻌ ﺎ ؟ ﻌﻤ ﯿﺳ ﺘ ﻢ ﺦﺴﻧ ﺔﺒﻗاﺮﻤﻟا ﻦﻣ ﻞﺒﻗ ﺚﺣﺎﺒﻟا فﻮﺳو نﻮﻜﯾ ﻞﻜﻟ ﺸﻣ ﺎ كر ﻮھ ﯾ ﮫ ﻔﺸﻣ ﺮ ة . ﯿﺳ ﺘ ﻢ ﻦﯾﺰﺨﺗ ﻤﺟ ﯿ ﻊ تﺎﻧﺎﯿﺒﻟا ﻞﻜﺸﺑ ﻦﻣآ ﺳو ﯿ ﺘ ﻢ ﻦﯾﺰﺨﺗ تﺎﻧﺎﯿﺒﻟا ﻟﻹا ﻧوﺮﺘﻜ ﺔﯿ ﻰﻠﻋ ﮭﺟ ﺎ ز ﻤﻛ ﺒ ﺮﺗﻮﯿ ﻲﻤﺤﻣ ﺔﻤﻠﻜﺑ روﺮﻣ .

ﺔﯿﻔﯿﻛ ﻔﺤﻟا ظﺎ ﻰﻠﻋ ﺔﯾﺮﺴﻟا ﻲﻓ ؟ﺚﺤﺒﻟا ﺪﻌﺑ ﻊﻤﺟ تﺎﻣﻮﻠﻌﻤﻟا ﻞﻠﺤﺘﺳ ﻞﻜﺸﺑ ﻻ ﺮﮭﻈﺗ ﻮھ ﯾ ﮫ كرﺎﺸﻤﻟا ﺚﯿﺤﺑ ﺮﮭﻈﺘﺳ ﯾﺮﻄﺑ ﻘ ﮫ ﻮﮭﺠﻣ ﻟ ﺔ ( ﺰﻣﺮﺑ كرﺎﺸﻤﻟا .) ﯿﺳ ﺘ ﻢ ﻦﯾﺰﺨﺗ تارﺎﻤﺘﺳا ﺔﻘﻓاﻮﻤﻟا ﻲﻓ ﺰﺧ ا ﻧ ﺔ ﻠﻣ تﺎﻔ ﮫﺼﺼﺨﻣ ﻐﻣو ﻠ ﻘ ﮫ ﺳو ﯿ ﺘ ﻢ ﻦﯾﺰﺨﺗ ﺎﮭﻨﯾوﺪﺗ ﻰﻠﻋ ﮭﺟ ﺎ ز ﻤﻛ ﺒ ﺮﺗﻮﯿ ﻲﻤﺤﻣ ﺔﻤﻠﻜﺑ روﺮﻣ . ﻦﻟ ﺮﮭﻈﺗ ءﺎﻤﺳأ ﻦﯿﻛرﺎﺸﻤﻟا ﺗو ﻔ ﺻﺎ ﻢﮭﻠﯿ ﻲﻓ يأ ﻦﻣ ﻖﺋﺎﺛﻮﻟا ،ﺔﻋﻮﺒﻄﻤﻟا ﯿﺳ ﺘ ﻢ ضﺮﻋ يأ تﺎﺳﺎﺒﺘﻗا ﻦﻣ ﺮﯿﻏ ﮭظ رﻮ يأ ﻦﻣ ﻌﻣ ﻠ ﻣﻮ تﺎ ﻦﯿﻛرﺎﺸﻤﻟا . ﯿﺳ ﺘ ﻢ ﺘﺣﻻا ﻔ ظﺎ ﺎﻜﺑ ﺔﻓ تﺎﻧﺎﯿﺒﻟا ةﺪﻤﻟ ١٠ ﻮﻨﺳ تا ﻲﻠﻋ ﺐﺴﺣ اﻮﻗ ﻧ ﻦﯿ او ﮫﻤﻈﻧ ﺎﺟ ﺔﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ . ﯿﺳ نﻮﻜ ﻂﻘﻓ يﺪﻟ ﻓﺮﺸﻣ ﯿ ﻦ ﺚﺣﺎﺒﻟا ﺔﯿﺻﺎﺨﻟا لﻮﺻﻮﻠﻟ ﻲﻟا تﺎﻧﺎﯿﺒﻟا . .

اذﺎﻣ ثﺪﺤﯾ اذإ ﺖﻨﻛ ﻻ ﺪﯾﺮﺗ نأ ﺎﺸﺗ كر وأ اذإ ﺖﻤﻗ ﺮﯿﯿﻐﺘﺑ أر ؟ﻲﯾأ ﺮﻣﻷا كوﺮﺘﻣ ﻚﻟ رﺮﻘﺘﻟ ﺎﻣ اذإ ﺖﻨﻛ دﻮﺗ ﺔﻛرﺎﺸﻤﻟا مأ ﻻ . ﻚﻟﺬﻟ اذإ ﺎﻣ ترﺮﻗ نأ ﺬﺧﺄﺗ رود ﻲﻓ ﺚﺤﺒﻟا ﺘﺳ ﻰﻄﻌ رو ﻗ ﺔ ﺔﻘﻓاﻮﻤﻟا ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ﺚﺤﺒﻟا ﺳو ﯿ ﻄ ﺐﻠ ﻚﻨﻣ ﻊﯿﻗﻮﺘﻟا ﻰﻠﻋ ةرﺎﻤﺘﺳﻻا . اذإ ترﺮﻗ ﺔﻛرﺎﺸﻤﻟا ﺖﻧﺂﻓ ﺮﺣ ﻲﻓ بﺎﺤﺴﻧﻻا ﻲﻓ يأ ﻠﺣﺮﻣ ﮫ ﻦﻣ ﺮﻣ ا ﻞﺣ ﺚﺤﺒﻟا نود ءاﺪﺑإ يأ ﺐﺒﺳ ﻦﻣ ﺒﺳﻷا بﺎ .

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ﻞھ ﺪﺟﻮﯾ ﻊﻓد ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ؟ﺚﺤﺒﻟا ﻻ ﺪﺟﻮﯾ يأ ﻊﻓد ﺔﻛرﺎﺸﻤﻠﻟ ﻲﻓ ﺚﺤﺒﻟا . ﺎﻣ ﻲھ ةﺪﻣ ؟ﺚﺤﺒﻟا ﯿﺳ ﺐﻠﻄﺘ ﺚﺤﺒﻟا هﺪﻣ ﻻ ﻞﻘﺗ ﻦﻋ ثﻼﺛ ﻮﻨﺳ تا ﻦﻜﻟو ﺐﻠﻄﯿﺳ ﻚﻨﻣ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺔﺒﻗاﺮﻤﻟا هﺪﻤﻟ حواﺮﺘﺗ ﻦﻣ ٢٠-٣٠ ﺔﻘﯿﻗد . . ﻦﯾا ﯿﺳ ﺘ ﻢ ءاﺮﺟإ ؟ثﻮﺤﺒﻟا ﺘﺳ ﺘ ﻢ ﻗاﺮﻤﻟا ﺔﺒ ﻲﻓ ﺰﻛﺮﻤﻟا ﻲﺤﺼﻟا لﻼﺧ ةﺮﺘﻓ ﺮﻣ ا ﻌﺟ ﻚﺘ ﺔﻌﺑﺎﺘﻤﻠﻟ ﻲﻓ ﺖﻗﻮﻟا او ﻟ مﻮﯿ او نﺎﻜﻤﻟ يﺬﻟا دﺪﺤﺘﺳ ه . . ﻞھ ﯿﺳ ﺘ ﻢ ﺮﺸﻧ ﺞﺋﺎﺘﻧ ؟ثﺎﺤﺑﻷا ﻞﻣﺄﻧ نأ ﺮﺸﻨﺗ ﺞﺋﺎﺘﻨﻟا ﻲﻓ تﻼﺠﻤﻟا ﺔﯿﻀﯾﺮﻤﺘﻟا او ﺔﯿﺒﻄﻟ او تﻻﺎﺠﻤﻟ ﺔﯿﺤﺼﻟا ىﺮﺧﻷا ﺔﯿﻠﺤﻤﻟا او ﻟوﺪﻟ ﺔﯿ . ﺑو ﺔﻓﺎﺿﻹﺎ ﻰﻟإ ،ﻚﻟذ ﻞﻣﺄﻧ ﺎﻀﯾا نأ مﺪﻘﺗ ﺞﺋﺎﺘﻨﻟا اﺮﻤﺗﺆﻤﻟا ت ﺔﯿﻀﯾﺮﻤﺘﻟا او ﺔﯿﺒﻄﻟ او تﻻﺎﺠﻤﻟ ﺔﯿﺤﺼﻟا ىﺮﺧﻷا ﺔﯿﻠﺤﻤﻟا او ﻟوﺪﻟ ﺔﯿ . اذإ ﺖﻨﻛ ﺐﻏﺮﺗ ﻲﻓ لﻮﺼﺤﻟا ﻰﻠﻋ ﺔﺨﺴﻧ ﻦﻣ تارﻮﺸﻨﻤﻟا ﻨﺳ نﻮﻜ ﻌﺳ ﺪ ا ء ﻞﺳﺮﻨﻟ ﻚﻟ ﮫﺨﺴﻧ ﻦﻣ ﻦﯾا ﻞﺼﺣ ﺮﺸﻣ عو ﺚﺤﺒﻟا ﻰﻠﻋ ؟ﺔﻘﻓاﻮﻤﻟا ﺪﻘﻟ ﺖﻤﺗ ﺮﻣ ا ﮫﻌﺟ ﺚﺤﺒﻟا هدﺎﻤﺘﻋاو ﻦﻣ ﻞﺒﻗ ﺔﻨﺠﻟ ﻗﻼﺧﻷا ﯿ تﺎ ﻦﻣ ﺎﺟ ﺔﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ ﻦﻣو ﻞﺒﻗ ﺔﻨﺠﻟ ﺧأ ﻗﻼ ﯿ تﺎ ثﻮﺤﺒﻟا ﻦﻣ زو ا ر ة ﺔﺤﺼﻟا ﻨﻄﻠﺴﺑ ﺔ ﻤﻋ ﺎ ن . اذﺎﻣ ﻮﻟ ثﺪﺣ ﻄﺧ ﺄ ؟ﺎﻣ ﻻ ﻊﻗﻮﺘﻧ ثوﺪﺤﺑ يا ﺮﻄﺧ وا ﻄﺧ ﺎ ﺒﻣ ﺮﺷﺎ ﻚﻟ ﻲﻓ ﺬھ ه ﺔﺳارﺪﻟا . نﺎﻓ او ﺖﻘﻓ ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﺖﻧﺄﻓأ ﺖﺴﻟ ﺖﺤﺗ يأ ماﺰﺘﻟا ﻲﻀﻤﻠﻟ ﺎﻣﺪﻗ ﻼﻓ ﺐﺠﯾ ﻠﻋ ﻚﯿ ءﺎﻄﻋإ يأ ﺐﺒﺳ ﻲﻓ ﺎﺣ ﻟ ﮫ ﺪﻋ م ﺔﻛرﺎﺸﻤﻟا . اذإ نﺎﻛ ﻨھ كﺎ ﺎﻣ ﻚﺠﻋﺰﯾ وا ﺮﯿﺜﯾ ؤﺎﺴﺗ ﻚﻟ ﺔﺳارﺪﻟﺎﺑ ﻲﺟﺮﯾ لﺎﺼﺗﻻا ﺎﯿﻧوﺮﺘﻜﻟا ﻰﻠﻋ ﻟا ﯾﺮﺒ ﺪ ﻲﻟﺎﺘﻟا : [email protected]

ﺮﻜﺷ ا ﺧﻷ ﺬ ﺖﻗﻮﻟا ﻲﻓﺎﻜﻟا ةءاﺮﻘﻟ ﺬھ ه تﺎﻣﻮﻠﻌﻤﻟا .

ﺖﻤﺗ ﺔﻘﻓاﻮﻤﻟا ﻠﻋ ﻰ عوﺮﺸﻤﻟا ﻦﻣ ﻞﺒﻗ ﮫﻨﺠﻟ ﻗﻼﺧﻻا ﯿ تﺎ ﺎﺠﺑ ﮫﻌﻣ ﺎﻣ ﺮﺘﺴﺸﻧ [١٦٣٤٦]

401 Appendix 21: Consent Form for Postnatal Mother/ Interview (Arabic)

Appendix 29: Consent Form for Postnatal Mother Interview (Arabic)

ثﺪﺤﺘﻟا ﻊﻣ تﺎﮭﻣﻻا تﺎﯿﻧﺎﻤﻌﻟا ﻦﻋ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا

رادﺻﻹا لوﻷا وﯾﺎﻣ ٢٠١٦

ﺗﺳا ﻣ ﺎ ةر ﺔﻘﻓاوﻣﻟا ﺔﻛرﺎﺷﻣﻠﻟ ﻲﻓ ﺔﺳاردﻟا ( تﺎﮭﻣﻸﻟ دﻌﺑ )ةدﻻوﻟا

ﻰﺟرﯾ ارﻗ ةء ﻊﺿوو ا فورﺣﻟ ﻰﻟوﻷا نﻣ كﻣﺳا ﺎﺟﺑ بﻧ ا ﻟ ﺑ ﯾ ﺎ ﻧ تﺎ أ د ﻧ ﺎ ه نﻣو ﺛ م ا ﻟ ﻗوﺗ ﻊﯾ ﻰﻠﻋ ا ءزﺟﻟ ﻲﻠﻔﺳﻟا نﻣ جذوﻣﻧﻟا ثﯾﺣ بﺗﻛﺗ مﺳا .كرﺎﺷﻣﻟا ﻰﺟرﯾ درﻟا درﻟا ﻰﻠﻋ لﻛ ﺋﺳﻷا ﻠ ﺔ

ﻊﺿ فورﺣﻟا ﻰﻟوﻻا نﻣ كﻣﺳا ﻲﻓ ﻟا ﻣ تﺎﻌﺑر

١ دﻛؤا. ﻲﻧﻧأ تأرﻗ تﻣﮭﻓو ﺔﻗرو تﺎﻣوﻠﻌﻣﻟا ﺦﯾرﺎﺗﺑ وﯾﺎﻣ ٢٠١٦ رادﺻﻻا( )لوﻷا ﻟ ﺔﺳاردﻠ ةروﻛذﻣﻟا ،هﻼﻋأ دﻗو تﺣﯾﺗا ﻲﻟ ﺔﺻرﻔﻟا حرطﻟ يأ لاؤﺳ ﻟ ﻠ ﺑ ثﺣﺎ ﺎﻣﯾﻓ قﻠﻌﺗﯾ ﺑ ﺎ .ﺔﺳاردﻟ .ﺔﺳاردﻟ ﺎ ﺑ قﻠﻌﺗﯾ ﺎﻣﯾﻓ ثﺣﺎ ﺑ ﻠ ﻟ لاؤﺳ يأ ٢ ﺎﻧأ. مﮭﻓأ نأ ﻲﺗﻛرﺎﺷﻣ ﺔﯾﻋوط ﺎﻧأو رﺣ ﻲﻓ بﺎﺣﺳﻧﻻا نﻣ ﺔﺳاردﻟا ﻲﻓ يأ تﻗو نود ءادﺑإ يأ ،بﺑﺳ نأو ﺔﯾﺎﻋرﻟا ﺔﯾﺣﺻﻟا ﺔﺻﺎﺧﻟا ﻲﺑ نﻟ رﺛﺄﺗﺗ .كﻟذﺑ

٣ ﺎﻧأ. كردأ ﮫﻧا ﻻ ﻲﻧﻧﻛﻣﯾ بﺣﺳ تﺎﻧﺎﯾﺑﻟا ﻲﻓ ﺔﻟﺎﺣ لوﺻو ثﺣﺎﺑﻟا ﺔﻠﺣرﻣﻟ لﯾﻠﺣﺗ تﺎﻧﺎﯾﺑﻟا وأ رﺷﻧ .تﺎﻧﺎﯾﺑﻟا ﺎﻧأ اوأ قﻓ ﻰﻠﻋ .كﻟذ

٤. ﺎﻧأ كردأ نأ ﺔﻠﺑﺎﻘﻣﻟا فوﺳ لﺟﺳﺗ ( ﻻو أ دﺣ ا رﺧ ىوﺳ ﻓ ر قﯾ ا ﻟ ثﺣﺑ نﻛﻣﯾ نأ لﺻﯾ ا ﻰﻟ ا ﻟ تﻼﯾﺟﺳﺗ ،) او ﻟ ﻰﺗ مﺗﯾﺳ ﯾزﺧﺗ ﺎﮭﻧ ﻲﻓ نﺎﻛﻣ نﻣآ فوﺳو رﻣدﺗ درﺟﻣﺑ ﺗﻛ ﺔﺑﺎ ا .ﺔﺳاردﻟ أ ﻧ ﺎ اوأ قﻓ ﻰﻠﻋ اذھ . ٥ قﻓاوأ. ﻰﻠﻋ مادﺧﺗﺳا تﺎﺳﺎﺑﺗﻗﻻا ةرﺷﺎﺑﻣﻟا ﻲﻟ ﻲﻓ يأ رﯾرﺎﻘﺗ وأ تاروﺷﻧﻣ اذإ مﺗ ﺎﮭﻣادﺧﺗﺳا ﺔﻘﯾرطﺑ تﻟ مﺗﯾ فﯾرﻌﺗﻟا .ﻲﻠﻋ

٦ ﺎﻧأ. كردأ ﮫﻧأ فوﺳ مﺗﯾ نﯾزﺧﺗ تﺎﻧﺎﯾﺑﻟا ﻲﻓ نﺎﻛﻣ نﻣآ فوﺳو رﻣدﯾ تﺎﻧﺎﯾﺑﻟا دﻧﻋ ءﺎﮭﺗﻧﻻا نﻣ .ﺔﺳاردﻟا ﺎﻧأ اوأ قﻓ ﻰﻠﻋ اذھ .

٧ . ﺎﻧا كردا نا هذھ تﺎﻣوﻠﻌﻣﻟا فوﺳ كرﺎﺷﯾ ﺎﮭﺑ اذا سﺣا نﺎﺛﺣﺎﺑﻟا كﺎﻧھ ررﺿ ﻲﻟ .لﻔطﻠﻟو

انأ اوأ قف ىلع ةكراشلا يف عورشلا روكذلا هلعأ

______مﺳإ كرﺎﺷﻣﻟا ﻗوﺗﻟا ﻊﯾ ﺦﯾرﺎﺗﻟا

______مﺳإ ا ﻟ ثﺣﺎﺑ ﻊﯾﻗوﺗﻟا ﺦﯾرﺎﺗﻟا ﺦﯾرﺎﺗﻟا

فوﺳ نوﻛﯾ كدﻧﻋ ﺔﺧﺳﻧ نﻣ اذھ ا ﻟ جذوﻣﻧ ﻟ ﻔﺣﻠ ظﺎ ﻠﻋ ﮫﯾ ﯾﺳو مﺗ زﺧﺗ نﯾ ا ﻟ ﺔﺧﺳﻧ ىرﺧﻻا ﻲﻓ ﻣ فﻠ ا ﻟ ﺑ .ثﺣﺎ .ثﺣﺎ ﺑ ﻟ ا فﻠ ﻣ ﻲﻓ ىرﺧﻻا ﺔﺧﺳﻧ ﻟ ا نﯾ

ﺔﺛﺣﺎﺑﻟا ﻲھ ﻟز ﺔﺧﯾ ا ﻲﻗوزرﻣﻟ نﻣ ﻠﻛ ﺔﯾ ا ﻟ ،ضﯾرﻣﺗ ا ﻟ ﻘ ﺑ ﺎ ﺔﻟ او لﻣﻌﻟ ،ﻲﻋﺎﻣﺗﺟﻻا ﺔﻌﻣﺎﺟ ﺎﻣ ،رﺗﺳﺷﻧ ﺑ ﻧ ﺎ ﺔﯾ نﺎﺟ ﻔﻛﺎﻣ ﻟرﺎ نﯾ ، عرﺎﺷ دروﻔﺳﻛإ ، ،رﺗﺳﺷﻧﺎﻣ ، M13 9HA ﻰﻠﻋ ا ﻟ ﯾرﺑ د ﻟﻻا ﻛ ﻲﻧورﺗ [email protected]

402 Appendix 22: Consent Form for Family Members/ Interview (Arabic) Appendix 30: Consent Form for Fam ily Mem bers of Postnatal Mothers Interview (Arabic)

ثدﺣﺗﻟا ﻊﻣ تﺎﮭﻣﻻا تﺎﯾﻧﺎﻣﻌﻟا نﻋ ﺔﻋﺎﺿرﻟا ﺔﯾﻌﯾﺑطﻟا رادﺻﻹا لوﻷا ﺎﻣ وﯾ ٢٠١٦ ﺗﺳا ﻣ ﺎ ةر ﺔﻘﻓاوﻣﻟا ﺔﻛرﺎﺷﻣﻠﻟ ﻲﻓ ﺔﺳاردﻟا ﻋ( ﺎ ﺋ ﻠ ﺔ ا ﮭﻣﻻ )تﺎ

ﻰﺟرﯾ ارﻗ ةء ﻊﺿوو ا فورﺣﻟ ﻰﻟوﻷا نﻣ كﻣﺳا ﺎﺟﺑ بﻧ ا ﻟ ﺑ ﯾ ﺎ ﻧ تﺎ أ ﻧد ﺎ ه نﻣو مﺛ ا ﻟ ﻗوﺗ ﻊﯾ ﻰﻠﻋ ا ءزﺟﻟ ﻲﻠﻔﺳﻟا نﻣ جذوﻣﻧﻟا ثﯾﺣ

بﺗﻛﺗ مﺳا .كرﺎﺷﻣﻟا

ﻰﺟرﯾ درﻟا ﻰﻠﻋ لﻛ ﺔﻠﺋﺳﻷا ﻊﺿ فورﺣﻟا ﻰﻟوﻻا نﻣ كﻣﺳا ﻲﻓ ﻟاﻣ تﺎﻌﺑر

١ دﻛؤا. ﻲﻧﻧأ تأرﻗ تﻣﮭﻓو ﺔﻗرو تﺎﻣوﻠﻌﻣﻟا ﺦﯾرﺎﺗﺑ وﯾﺎﻣ ٢٠١٦ رادﺻﻻا( )لوﻷا ﻟ ﺔﺳاردﻠ ةروﻛذﻣﻟا ،هﻼﻋأ دﻗو ا ﺗ تﺣﯾ ﻲﻟ ا ﻟ ﺔﺻرﻔ حرطﻟ يأ لاؤﺳ ﻟ ﻠ ﺑ ثﺣﺎ ﻓ ﺎﻣﯾ ﯾ قﻠﻌﺗ ﺑ ﺎ ﻟ .ﺔﺳارد .ﺳر ﻠﺗﯾ ﺎﯾﻓثﺎﺑﻠﻟلؤ أحط ﺔر ﻟتﯾﺗا ﻗ ٢ ﺎﻧأ. مﮭﻓأ نأ ﻲﺗﻛرﺎﺷﻣ ﺔﯾﻋوط ﺎﻧأو رﺣ ﻲﻓ بﺎﺣﺳﻧﻻا نﻣ ﺔﺳاردﻟا ﻲﻓ يأ تﻗو نود ءادﺑإ يأ .بﺑﺳ

٤. ﺎﻧأ كردأ نأ ﺔﻠﺑﺎﻘﻣﻟا فوﺳ لﺟﺳﺗ ( ﻻو أ دﺣ ا رﺧ ىوﺳ ﻓ ر قﯾ ا ﻟ ثﺣﺑ نﻛﻣﯾ نأ لﺻﯾ ا ﻰﻟ ا ﻟ تﻼﯾﺟﺳﺗ ،) او ﻟ ﻰﺗ ﯾﺳ ﺗ م ﺎﮭﻧﯾزﺧﺗ ﻲﻓ نﺎﻛﻣ آ نﻣ فوﺳو ﺗ د رﻣ ﺑ درﺟﻣ ﺗﻛ ﺎ ﺔﺑ ا ﻟ .ﺔﺳارد أ ﻧ ﺎ اوأ قﻓ ﻰﻠﻋ اذھ . ٥ قﻓاوأ. ﻰﻠﻋ مادﺧﺗﺳا تﺎﺳﺎﺑﺗﻗﻻا ةرﺷﺎﺑﻣﻟا ﻲﻟ ﻲﻓ يأ رﯾرﺎﻘﺗ وأ تاروﺷﻧﻣ اذإ مﺗ ﺎﮭﻣادﺧﺗﺳا ﺔﻘﯾرطﺑ تﻟ مﺗﯾ فﯾرﻌﺗﻟا .ﻲﻠﻋ

٦ ﺎﻧأ. كردأ ﮫﻧأ فوﺳ مﺗﯾ نﯾزﺧﺗ تﺎﻧﺎﯾﺑﻟا ﻲﻓ نﺎﻛﻣ نﻣآ فوﺳو رﻣدﯾ تﺎﻧﺎﯾﺑﻟا دﻧﻋ ءﺎﮭﺗﻧﻻا نﻣ .ﺔﺳاردﻟا ﺎﻧأ

اوأ قﻓ ﻰﻠﻋ اذھ .

انأ اوأ قف ىلع ةكراشلا يف عورشلا روكذلا لعأ ه

______مﺳا كرﺎﺷﻣﻟا ﻊﯾﻗوﺗﻟا ﺦﯾرﺎﺗﻟا

______مﺳا ﻟا ثﺣﺎﺑ ﻊﯾﻗوﺗﻟا ﺦﯾرﺎﺗﻟا

فوﺳ نوﻛﯾ ﻧﻋ كد ﺔﺧﺳﻧ نﻣ ذھ ا ا ﻟ جذوﻣﻧ ﻟ ﻔﺣﻠ ظﺎ ﻠﻋ ﯾ ﮫ ﯾﺳو ﺗ م نﯾزﺧﺗ ا ﻟ ﺔﺧﺳﻧ ىرﺧﻻا ﻲﻓ فﻠﻣ ا ﻟ ﺑ .ثﺣﺎ

ﺔﺛﺣﺎﺑﻟا ﻲھ ﻟز ﺔﺧﯾ ا ﻲﻗوزرﻣﻟ نﻣ ﻠﻛ ﯾ ﺔ ا ﻟ ،ضﯾرﻣﺗ ا ﻟ ﻘ ﺑ ﺎ ﻟ ﺔ او لﻣﻌﻟ ،ﻲﻋﺎﻣﺗﺟﻻا ﺔﻌﻣﺎﺟ ﺎﻣ ،رﺗﺳﺷﻧ ﺑ ﻧ ﺎ ﯾ ﺔ نﺎﺟ ﻔﻛﺎﻣ ﻟرﺎ ،نﯾ عرﺎﺷ دروﻔﺳﻛإ ، ﺎﻣ ،رﺗﺳﺷﻧﺎ M13 9HA ﻰﻠﻋ ا ﻟ ﯾرﺑ د ﻲﻧورﺗﻛﻟﻻا [email protected]

403 Appendix 23: Consent Form for Postnatal Mother/ Observation (Arabic) Appendix 31: Consent Form for Postnatal Mother Observation (Arabic)

التحدث مع المهات العمانيات عن الرضاعة الطبيعية

الصدار الول مايو ٢٠١٦ استمارة الموافقة للمشاركة في الدراسة )مراقبة المهات بعد الولدة(

يرجى قراءة ووضع الحروف الولى من اسمك بجانب البيانات أدناه ومن ثم التوقيع على الجزء السفلي من النموذج حيث تكتب اسم المشارك. يرجى الرد على كل السئلة

ضع الحروف الولى من اسمك في المربعات

١.اؤكد أنني قرأت وفهمت ورقة المعلومات بتاريخ مايو ٢٠١٦ )الصدار الول( للدراسة المذكورة أعله، وقد اتيحت لي الفرصة لطرح أي سؤال للباحث فيما يتعلق بالدراسة. ٢.أنا أفهم أن مشاركتي طوعية وأنا حر في النسحاب من الدراسة في أي وقت دون إبداء أي سبب.

٣.أنا أدرك انه ل يمكنني سحب البيانات في حالة وصول الباحث لمرحلة تحليل البيانات أو نشر البيانات. أنا أوافق على ذلك.

٤.أنا أدرك أن المراقبة سوف تكتب على ورق )ول أحد اخر سوى فريق البحث يمكن أن يصل الى الشرطة(، والتى سيتم تخزينها في مكان آمن. أنا أوافق على هذا.

٥. انا أدرك ان المراقبة سوف تتمركز على ممارسة القابلة في المؤسسات الصحية. أوافق على ذلك.

٦.أنا أدرك أنه سوف يتم تخزين البيانات في مكان آمن وسوف يدمر البيانات عند النتهاء من الدراسة. أنا أوافق على هذا.

أنا أوافق على المشاركة في المشروع المذكور أعله

______إسم المشارك التوقيع التاريخ

______إسم الباحث التوقيع التاريخ

سوف يكون عندك نسخة من هذا النموذج للحفاظ عليه وسيتم تخزين النسخة الخرى في ملف الباحث.

الباحثة هي زليخة المرزوقي من كلية التمريض، القبالة والعمل الجتماعي، جامعة مانشستر، بناية جان ماكفارلين، شارع إكسفورد، مانشستر، M13 9HA على البريد اللكتروني [email protected]

404 Appendix 24: Distress Policy

A ppendix 14: Distress Policy

• A participant indicates they are experiencing a high level of stress or emotional distress, OR • A participant exhibits behaviours suggestive that the interview is Distress too stressful such as uncontrolled crying, incoherent speech, etc

• Stop the individual interview immediatly. • The researcher as a healthcare professional will provide an Stage 1 immediate support to the participant. • Allow participant time to relax. Response

• If the participant feels able to continue: then resume the interview. • If the participant is unable to carry on: go to Stage 2. Review

• Remove the participant from the interview area to a quite area, or stop individual interview. • Encourage participant to contact the GP, family member or Stage 2 friend, OR Response • Offer, with participant consent, for the researcher to do so for them.

• If the participant consents, follow up with a courtesy call the next day, OR • Encourage the participant to call a member of the research team if she experiences increased distress in the hours or days Follow up following the interview. • If appropriate, direct the participant to a breastfeeding couselor support.

Adapted from Haigh and Witham (2010)

405 Appendix 25: Lone Working Policy

Lone Working Policy

The researcher will work alone during the home visit to conduct the interviews, so she will keep in the mind the following: 1. Conduct risk assessment before conducting the interviews: • Knowing the history of the person being visited. • Family circumstances. • Travelling to isolated or rural areas. • Communication availability. • Personal safety and security.

2. Ensure that the researcher aware of and understand the control measures to be taken: • The researcher attended a workshop on lone working policy.

3. Follow the safe system of work and other control measures: • Implementation of a management control system by ensuring that information is shared with colleagues such as where the lone worker is going; who they are visiting; contact address and telephone number; estimated arrival time and duration of visit and time expected to over.

4. The researcher will report any incidents occurring whilst working alone, by means of the University’s incident reporting system and will report to the supervisors.

406 Appendix 26: Orientation Workshop Outline with the Gatekeepers

An Outline of the Presentation with the Gatekeepers

Directorate General of Health services in North Batinah Governorate: An hour workshop

Orientation Workshop Outline:

Refreshment; Welcome all Gatekeepers; Introducing the researcher? What is the researcher doing? Introduction to the research study; Aims and objectives, and importance of the research study; The prospective participants of the study; Inclusions and exclusions criteria; The role of the gatekeepers; Why should they be involved in accessing the participants? How data will be collected for the study? Conclusion; Distribution of necessary documents.

407

Appendix 27: PIS for Postnatal Mothers Interview (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016

Participant Information Sheet

Postnatal Mothers: Interview

You are being invited to take part in a study exploring the experiences and views of women who are breastfeeding. I would like to talk to you 7 days after your baby is born and then again at 1, 2, 3, 4 months following the birth of your baby at your house or while you visiting the health clinics for your post-natal check-up or your child immunization. Please, read carefully the following information about the study, ask me any questions you like and feel free to discuss with your family and / or doctor and take the time to decide whether or not you want to participate in the study. Thank you for taking the time to read this.

Who will conduct the research? Zalikha Al-Marzouqi (Ph.D. student), who obtained a Master degree on professional health practice from Uclan University in 2007, Bachelor in Nursing from Villanova University in 2002. Recently, she is a nursing tutor in North Batinah Nursing Institute.

What is the purpose of the study? This study will investigate the views and perspectives of mothers to find out their experiences of breastfeeding at certain intervals at 7th day and at 1, 2, 3, 4 months after given birth. It is anticipated that information from this research study will help the Ministry of Health in Oman to improve care in the future for women who are breastfeeding. This proposed study will help to understand the experiences of Omani mothers in regard to breastfeeding.

Why have I been chosen? You have been chosen because you have given birth at X Hospital in North Batinah Governorate, you have initiated exclusive breastfeeding at hospital and you met the inclusion criteria of this study.

408 up to four months after childbirth. These interviews will take place either in the health clinic or at your house. The researcher will contact you to agree on suitable time and place for the interviews to minimize any inconvenience. The interviews will be tape recorded so the researcher will not miss any of your comments.

What happens to the data collected? All collected data will transcript and all participants will have specific encrypted identity so no one can recognize the participants. Data will be stored in encrypted servers with password protected.

How is confidentiality maintained? All collected information about you will be kept strictly confidential. Any information about you will be stored in a locked cabinet at the researcher working place in Oman and at The University of Manchester and on an encrypted server. The researcher will not name anyone in reports we write as an ethical part of the study. Also, the researcher will give people who are taking part pseudonyms and remove any information that could identify them. In addition to that, the researcher will not tell healthcare professionals who are responsible for your care and / or treatment if you have taken part in the study, unless it is felt that you or others within your family are at serious risk of harm. Furthermore, audio recorded data will be transcribed as soon as possible after conducting the transcription of the data, after which the audio recording will be deleted. All participant information will be securely retained at The University of Manchester for 10 years following the last publication of the study, in accordance with GCP guidelines. No data will be used for the future research.

What happens if I do not want to take part or if I change my mind? It is according to your decision whether or not to participate in this study. Even if you signed the consent form to take part, you are still free to withdraw at any time and without giving any reason. A decision to withdraw, or a decision not to take part in the study, will not affect the standard of care you receive now or in the future in any health institutions. However, if you participated you cannot withdraw collected data when the researcher reaches the time of anonymising transcriptions or at the time of the publication.

Will I be paid for participating in the research?

There will be no payment for participating in the research.

What is the duration of the research? The total duration of the research is three years. Your involvement will be taking part in different interviews at certain intervals (7th day and at 1, 2, 3, 4 months after childbirth), each interview will last approximately up to one hour. Also, you might be included in observation for 20-30 minutes in the healthcare institutions when observation will be conducted to observe how midwives promote the practice of breastfeeding at healthcare institutions.

Where will the research be conducted? The research will be conducted in the Ministry of Health institutions in North Batinah Governorate or at your house, according your desire.

409

Will the outcomes of the research be published? The researcher may publish the research study in related journals, so that others can learn from the study. Also, the researcher will give presentations at health related conferences to disseminate the information and results of this study. When using the quotation of what you said, the researcher will be careful to ensure that it is not possible for anyone to identify you as a participant in any reports, papers or presentations. If you participate in the study, the researcher will send to you a summary of the results when the study complete.

Who has reviewed the research project? This study will be reviewed by the supervisors of this study at The University of Manchester, The University of Manchester Research Ethics Committee (UREC) and the Ministry of Health ethical committee in Oman.

What if something goes wrong? The researcher does not anticipate that participating in this research study will cause you problems or harms. If, however, you are unhappy or have problems with any aspect of the way that you are treated, you should contact the ethical committee in the ministry of health in Oman at this email [email protected] and phone number 24697551. Also you can contact the lead supervisor of this study who is Professor Dame Tina Lavender at this email [email protected]. Any complaint you make will be taken very seriously. In addition to that, in order to protect you more, the project will be covered by The University of Manchester’s insurance for research studies. If any problems or issues arise that you do not want to raise with the research team, you will be able to contact the University Research Office at this number +44(0)161 275 7583. It is possible that the questions asked may raise issues and / or concerns for you. If this happens, you could ask the researcher to pass these on to the relevant person (the researcher will not tell your doctors or midwives about anything you have said unless you ask the researcher to do so or unless the researcher believes that either you or others are at serious risk of harm).

What if I want to make a complaint?

Minor complaints If you have minor complaints, you can contact the researcher or the research supervisor Professor Dame Tina Lavender on her email: [email protected], telephone number: +44 (0)161 306 7744.

Formal Complaints If you wish to make a formal complaint or if you are not satisfied with the response you have gained from the researchers in the first instance then please contact the Research Governance and Integrity Manager, Research Office, Christie Building, University of Manchester, Oxford Road, Manchester, M13 9PL, by emailing: [email protected] or by telephoning 0161 275 2674 or 275 2046.

What Do I Do Now? If you have any questions and / or you would like to participate in the study, please contact the researcher Zalikha Al-Marzouqi on this e-mail zalikha.al-

410 [email protected], telephone number 0096826846405 Extension: 2938.

Please feel free to discuss this information with others (e.g. your family or your doctor) before deciding whether or not to take part. You can also contact the research team directly (details above), if something is unclear. If you agree to take part in this study, I will contact you to arrange a time, venue and date that is best for you. Data collection can take place in your house or at health clinics.

Thank you for taking the time to read this information.

411 Appendix 28: Consent to Contact Form (English Version)

Consent to Contact Form Version 1, May 2016 Talking to Omani Mothers About Breast Feeding

You are being invited to give consent for Zalikha Al-Marzouqi to contact you at some point in the future about taking part a research study.

If yes, you will be contacted at a later date. Please tick your preferred method of contact that you would like the researcher to contact you.

☐ Telephone Number:

☐ Mobile Number: ☐ E-mail: ☐ Postal Address:

Please tick your preferred time for contact that you would like the researcher to contact you.

☐ Morning: ☐ Afternoon:

☐ Evening: ☐ Don’t mind at any time:

Every effort will be made to safeguard your contact information. Although access to this information will be limited, there is a small chance that this information could be inadvertently disclosed or inappropriately accessed.

You have been made aware of the reasons why the contact information is needed and the risks and benefits of consenting or refusing to consent.

Patient’s Signature: ______

Date: ______

412 Appendix 29: Consent to Contact Form (Arabic Version)

جذﻮﻤﻧ ﺔﻘﻓاﻮﻤﻟا ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺔﺳارﺪﻟا

راﺪﺻﻻا ١، ﺎﻣ ﻮﯾ ٢٠١٦

ثﺪﺤﺘﻟا ﻊﻣ تﺎﮭﻣﻻا تﺎﯿﻧﺎﻤﻌﻟا ﻦﻋ ﺔﻋﺎﺿﺮﻟا ﺔﯿﻌﯿﺒﻄﻟا

ﯿﺳ ﺘ ﻢ ﻮﻋد ﻚﺗ ﻄﻋﻹ ﺎ ء ﺔﻘﻓاﻮﻤﻟا ﻰﻠﻋ ﺔﻛرﺎﺸﻤﻟا ﻲﻓ ﺬھ ا عوﺮﺸﻤﻟا ﻦﻣ ﻞﺒﻗ ﺔﺜﺣﺎﺒﻟا ﻟز ﺔﺨﯿ ﻲﻗوزﺮﻤﻟا لﺎﺼﺗﻼﻟ ﻢﺑ ﻲﻓ ﻞﺒﻘﺘﺴﻤﻟا . .

اذإ ﺎﻛ ﺖﻧ ﺎﺟﻹا ﺑ ﺔ ،ﻢﻌﻨﺑ ﯿﺳ ﺘ ﻢ لﺎﺼﺗﻻا ﻚﺑ ﻲﻓ ﺖﻗو ﻖﺣﻻ . ﺮﯾ ﻰﺟ ﻊﺿو ﻼﻋ ﻣ ﺔ ﺢﺻ ﺔﮭﺠﻟ لﺎﺼﺗﻻا ﺔﻠﻀﻔﻤﻟا ﻚﻟ او ﻟ ﻲﺘ ﺐﻏﺮﺗ ﺚﺣﺎﺒﻟا نا ﻞﺼﺘﯾ ﻚﺑ . .

¨ ﻗر ﻢ ﻒﺗﺎﮭﻟا : ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ¨ ﻒﺗﺎﮭﻟا يﻮﻠﺨﻟا / لﺎﻘﻨﻟا : ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ¨ ﺪﯾﺮﺒﻟا ﻟﻻا ﻲﻧوﺮﺘﻜ : ـــــــــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــــــــــــ ¨ ﻨﺻ ﺪ قو ﺪﯾﺮﺒﻟا : ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

ءﺎﺟﺮﻟا ﻊﺿو ﻼﻋ ﻣ ﺔ ﺢﺻ ﻲﻓ ﺖﻗﻮﻟا ﺐﺳﺎﻨﻤﻟا لﺎﺼﺗﻼﻟ ﻚﺑ

¨ حﺎﺒﺼﻟا ¨ ﺪﻌﺑ ةﺮﯿﮭﻈﻟا ¨ ءﺎﺴﻤﻟا ¨ ﻲﻓ يا ﺖﻗو

فﻮﺳ نﻮﻜﯾ ﮭﺟ ﺔ لﺎﺼﺗﻻا ﻚﺑ ﻲﻓ يﺪﯾا ﮫﻨﯿﻣا ﺚﯿﺤﺑ ﻻ ﻦﻜﻤﯾ ﺣﻻ ﺪ لﻮﺻﻮﻟا ﮫﯿﻟا ﺪﻋ ا ﺚﺣﺎﺒﻟا . او ﺖﻧ فﺮﻌﺗ ﺐﺒﺳ لﺎﺼﺗﻻا ﻚﺑ . .

ﻗﻮﺗ ﻊﯿ كرﺎﺸﻤﻟا : ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

ﺦﯾرﺎﺘﻟا : ــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــ

413 Appendix 30: Consent Form for Postnatal Mothers Interview (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016 CONSENT FORM Postnatal Mothers: Interview

Please read and put your initials next to the statements below and then sign the bottom of the form where it says ‘name of participant’.

PLEASE RESPOND TO ALL OF THESE QUESTIONS Please initial box 1. I confirm that I have read and understand the information sheet dated May 2016 c (version 1) for the above study and have had the opportunity to ask a member of the research team any questions I may have about the study. 2. I understand that my participation is voluntary and that I am free to withdraw at any c time, without giving any reason, and without my medical care or legal rights being affected. 3. I understand that I cannot withdraw collected data when the researcher reaches the c time of anonymising transcriptions or at the time of the publication. I agree to this. 4. I am aware that the interview will be tape recorded (no one else, apart from the c researchers, will have access to the tapes), which will be stored in a secure location and destroyed by the researchers once the study has been written up. I agree to this.

5. I agree to use my direct quotes in any reports or publications, if they are used in such c a way that I will not be identified.

6. I am aware that the data will be stored in a secure location and destroyed by the c researchers once the study has been written up. I agree to this.

I agree to take part in this study

______Name of Participant Signature Date

______Lead Researcher Signature Date

You will have a copy of this form to keep. A further copy will be stored in the researcher’s site file.

Lead Researcher: Zalikha Al-Marzouqi, School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. Email: [email protected]

414 Appendix 31: Demographic Data for Postnatal Mothers

Date: Interview No: Code:

Participant Demographics, Obstetrical & Breastfeeding History for Postnatal Mothers

Note: To be abstracted from the medical record or verbally from the participants after obtaining informed consent

Demographic data

Age in years: Date of birth: Occupation:

Marital Status (married/single/divorced/widowed):

Smoking History:

Highest level of education (high school diploma, college degree):

Obstetrical History

Date & time of infant birth:

(Gravida, Para, Term, Preterm, Abortions, Living):

Ages of prior children:

Breastfeeding History

415 Number of children for whom breastfeeding was attempted:

Duration (months/days) for each breastfeeding attempt (exclusive breastfeeding):

Current Birth

Type of birth:

Onset of labor (natural or induced):

Obstetric caregiver (Midwife, MD):

Continuity of nurse caregivers in hospital?

Infant data at birth:

Week of gestation at birth:

Weight: Length:

Apgar Scores (1 min/5 min):

Initiate of breastfeeding (Yes/ No):

416 Appendix 32: PIS for Family members Interview (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016

Participant Information Sheet

Family Member of Postnatal Mother

You are being invited to take part in a study exploring the views of family members of post-natal mothers who are breastfeeding. We would like to talk to you at any time during this study. Please, read carefully the following information about the study, ask me any questions you like and feel free to discuss with your family and take the time to decide whether or not you want to participate in the study.

What is the purpose of the study? This study will investigate the views and perspectives of women and their families on breastfeeding. We want to understand the views of family members on breastfeeding to find out your perspectives and how family members support the women during this period. It is anticipated that information from this research study will help the Ministry of Health in Oman to improve care in the future for women who are breastfeeding. This proposed study will help to understand the experiences of Omani mothers in regards to breastfeeding.

Why have I been chosen? You have been chosen because you are one of the family members of a mother who are breastfeeding and who had participated in this study.

What would I be asked to do if I took part? If you agree to be involved in this study, you will be asked to sign two copies of the consent form, one will be given to you and the other one will be kept with the researcher. The researcher will contact you to agree on time and place to conduct the interviews. The researcher will discuss your perspectives of breastfeeding and how you support a mother who are breastfeeding. These interviews will take place at you house. The aim of the researcher is to conduct the interview at a time and place suitable to you to minimize any inconvenience. The interviews will be tape recorded so the researcher will not miss any of your comments.

417

How is confidentiality maintained? All collected information about you will be kept strictly confidential. All information about you will be stored in a locked cabinet at the researcher working place in Oman and at The University of Manchester and on an encrypted server. The researcher will not name anyone in reports we write as an ethical part of the study. Also, the researcher will give people who are taking part pseudonyms and remove any information that could identify them. In addition to that, the researcher will not tell healthcare professionals who are responsible for your care and / or treatment if you have taken part in the study, unless it is felt that you or others within your family are at serious risk of harm. Furthermore, audio recorded data will be transcribed as soon as possible after conducting the transcription of the data, after which the audio recording will be deleted. All participant information will be securely retained at The University of Manchester for 10 years following the last publication of the study, in accordance with GCP guidelines. No data will be used for the future research.

What happens if I do not want to take part or if I change my mind? It is according to your decision whether or not to participate in this study. Even if you signed the consent form to take part, you are still free to withdraw at any time and without giving any reason. However, if you participated you cannot withdraw collected data when the researcher reaches the time of anonymising transcriptions or at the time of the publication.

Will I be paid for participating in the research? There will be no payment for participating in the research.

What is the duration of the research? Your involvement will be taking part in one interview and interview will last approximately up to one hour.

Where will the research be conducted? The research will be conducted at your house or any place you like.

Will the outcomes of the research be published? The researcher may publish the research study in related journals, so that others can learn from the study. Also, the researcher will give presentations at health related conferences to disseminate the information and results of this research study. When using the quotation of what you said, the researcher will be careful to ensure that it is not possible for anyone to identify you as a participant in any reports, papers or presentations. If you participate in the study, the researcher will send to you a summary of the results when the study complete.

418

Who has reviewed the research project? This study will be reviewed by the supervisors at The University of Manchester, The University of Manchester Research Ethics Committee (UREC) and the Ministry of Health ethical committee in Oman.

What if something goes wrong? The researcher does not anticipate that participating in this study will cause you problems or harms. If, however, you are unhappy or have problems with any aspect of the way that you are treated, you should contact the ethical committee in the ministry of health in Oman at this email [email protected] and phone number 24697551. Also you can contact the lead supervisor of this study who is Professor Dame Tina Lavender at this email [email protected]. Any complaint you make will be taken very seriously. In addition to that, in order to protect you more, the project will be covered by The University of Manchester’s insurance for research studies. If any problems or issues arise that you do not want to raise with the research team, you will be able to contact the University Research Office at this number +44(0)161 275 7583. It is possible that the questions asked may raise issues and / or concerns for you. If this happens, you could ask the researcher to pass these on to the relevant person.

What if I want to make a complaint?

What Do I Do Now? If you have any questions and / or you would like to participate in the study, please contact the researcher Zalikha Al-Marzouqi on this e-mail zalikha.al- [email protected], telephone number 0096826846405 Extension: 2938.

Please feel free to discuss this information with others before deciding whether or not to take part. You can also contact the research team directly (details above), if something is unclear. If you agree to take part in an interview, I will contact you to arrange a time, venue and date that is best for you. The interview can take place in your house.

Thank you for taking the time to read this information.

419 Appendix 33: Consent Form Family Members (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016 Informed Consent

Postnatal Mother Family Members

Please read and put your initials next to the statements below and then sign the bottom of the form where it says ‘name of participant’.

PLEASE RESPOND TO ALL OF THESE QUESTIONS Please initial box

1. I confirm that I have read and understand the information sheet dated May 2016 c (version 1) for the above study and have had the opportunity to ask a member of the research team any questions I may have about the study.

2. I understand that my participation is voluntary and that I am free to withdraw at c any time, without giving any reason.

3. I understand that I cannot withdraw collected data when the researcher reaches the c time of anonymising transcriptions or at the time of the publication. I agree to this.

4. I am aware that the interview will be tape recorded (no one else, apart from the c researchers, will have access to the tapes), which will be stored in a secure location and destroyed by the researchers once the study has been written up. I agree to this.

5. I agree to use my direct quotes in any reports or publications, if they are used in c such a way that I will not be identified.

6. I am aware that the data will be stored in a secure location and destroyed by the c researchers once the study has been written up. I agree to this. I agree to take part in this study

______Name of Participant Signature Date ______Lead Researcher Signature Date

You will have a copy of this form to keep. A further copy will be stored in the researcher’s site file.

Lead Researcher: Zalikha Al-Marzouqi, School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. Email: [email protected]

420 Appendix 34: Poster Advertisement for Healthcare Professionals (Interview)

Appendix 40: Poster Advertisement for Healthcare Professionals Interview

Would you like to share your views on breastfeeding?

I am researching midwives’ and nurses’ opinions on breastfeeding and am keen to hear what you have to say.

Soon, I will be asking volunteers to speak to me about this.

If you want any further information, Please contact the researcher (Zalikha Al-Marzouqi) on ofﬁce telephone number: ????? Extension:????

421 Appendix 35: PIS for Healthcare Professionals Interview (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016

Participant Information Sheet

Healthcare Professionals: Interview

You are being invited to take part in a study exploring the views of midwives who are providing healthcare services to post-natal mothers. We would like to talk to you once at any time during this study. Please, read carefully the following information about the study, ask me any questions you like and feel free to discuss with your family or friends and take the time to decide whether or not you want to participate in the study.

What is the purpose of the study? This study will investigate midwives’ views on breastfeeding to find out how breastfeeding can be supported by the midwives and what problems exist in regards of breastfeeding services in Oman. It is anticipated that information from this research study will help the Ministry of Health in Oman to improve care in the future for women who are breastfeeding.

Why have I been chosen? You have been chosen because you are a midwife providing care to post-natal mothers in the Ministry of Health institutions in North Batinah Governorate.

What would I be asked to do if I took part? If you agree to be involved in this study, you will be asked to sign two copies of the consent form, one will be given to you and the other one will be kept with the researcher. The researcher will contact you to agree on time and place to provide Participant Information Sheet and the to conduct the interview. The interview will be conducted once during the study and it will last for approximately up to one hour. The interview will take place either on the health clinic where you work or at your house. The aim of the researcher is to conduct the interview at a time and place suitable to you to minimize any inconvenience. The interviews will be tape recorded so the researcher will not miss any of your comments.

422

What happens if I do not want to take part or if I change my mind? It is according to your decision whether or not to participate in this research study. Even if you signed the consent form to take part, you are still free to withdraw at any time and without giving any reason. However, if you participated you cannot withdraw collected data when the researcher reaches the time of anonymising transcriptions or at the time of the publication.

Will I be paid for participating in the research? There will be no payment for participating in the research.

What is the duration of the research? The total duration of the research is three years. Your involvement will be taking part in one interview which will last approximately up to one hour.

Where will the research be conducted? The research will be conducted in the Ministry of Health institutions in North Batinah Governorate or at your house, according to your desire.

Will the outcomes of the research be published? The researcher may publish the research study in related journals, so that others can learn from the study. Also, the researcher will give presentations at health related conferences to disseminate the information and results of this research study. When using the quotation of what you said, the researcher will be careful to ensure that it is not possible for anyone to identify you as a participant in any reports, papers or presentations. If you participate in the study, the researcher will send to you a summary of the results when the study complete.

Who has reviewed the research project?

423 This study will be reviewed by the supervisors of this study at The University of Manchester, The University of Manchester Research Ethics Committee (UREC) and the Ministry of Health ethical committee in Oman.

Please feel free to discuss this information with others before deciding whether or not to take part. You can also contact the research team directly (details above), if something is unclear. If you would like to take part. If you agree to take part in an interview, I will contact you to arrange a time, venue and date that is best for you. The interview can take place in your house or at your working place.

Thank you for taking the time to read this information.

424 Appendix 36: Consent Form for Healthcare Professionals Interview (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016 CONSENT FORM Healthcare Professionals: Interview

Please read and put your initials next to the statements below and then sign the bottom of the form where it says ‘name of participant’.

PLEASE RESPOND TO ALL OF THESE QUESTION Please initial box 1. I confirm that I have read and understand the information sheet dated May c 2016 (version 1) for the above study and have had the opportunity to ask a member of the research team any questions I may have about the study.

2. I understand that my participation is voluntary and that I am free to withdraw c at any time, without giving any reason.

3. I understand that I cannot withdraw collected data when the researcher reaches c the time of anonymising transcriptions or at the time of the publication. I agree to this. 4. I am aware that the interview will be tape recorded (no one else, apart from the c researchers, will have access to the tapes), which will be stored in a secure location and destroyed by the researchers once the study has been written up. I agree to this. 5. I agree to use my direct quotes in any reports or publications, if they are used c in such a way that I will not be identified. 6. I am aware that the data will be stored in a secure location and destroyed by c the researchers once the study has been written up. I agree to this.

I agree to take part in this study

______Name of Participant Signature Date ______Lead Researcher Signature Date

You will have a copy of this form to keep. A further copy will be stored in the researcher’s site file.

Lead Researcher: Zalikha Al-Marzouqi, School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. Email: [email protected]

425 Appendix 37: PIS for Postnatal Mothers / Observation (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016

Participant Information Sheet

Postnatal Mothers: Clinical Observation

You are being invited to take part in a study exploring the views of post-natal mothers who are breastfeeding. We would like to observe you while the midwives are providing care to you in the healthcare institutions. Please, read carefully the following information about the study, ask me any questions you like and feel free to discuss with your family and take the time to decide whether or not you want to participate in the study.

What is the purpose of the study? This study will investigate mothers’ views on breastfeeding, to find out how breastfeeding can be supported by the midwives and what problems exist in regards of breastfeeding services in Oman. It is anticipated that information from this research study will help the Ministry of Health in Oman to improve care in the future for women who are breastfeeding.

Why have I been chosen? You have been chosen because you are a mothers who receive care after giving birth to your child at the ministry of health institutions in North Batinah Governorate.

What would I be asked to do if I took part? If you agree to be involved in this study, you will be asked to sign two copies of the consent form, one will be given to you and the other one will be kept with the researcher. The researcher will contact you to agree on time and place to provide Participant Information Sheet and the to conduct the observation. The observation will be conducted once during your post-natal check –up and it will last for approximately 20-30 minutes. The aim of the researcher is to conduct the observation at a time and place suitable to you to minimize any inconvenience. During observation, the researcher will take notes so no data will be missed.

426 What happens to the data collected? All collected data will transcript and all participants will have specific encrypted identity so no one can recognize the participants. Data will be stored in encrypted servers with password protected.

Will I be paid for participating in the research? There will be no payment for participating in the research.

What is the duration of the research? The total duration of the research is three years. Your involvement will be taking part in one observation which will last approximately 20-30 minutes.

Where will the research be conducted? The research will be conducted in the Ministry of Health institutions in North Batinah Governorate during your post-natal check-up at second or sixth week after your childbirth.

Will the outcomes of the research be published? The researcher may publish the research study in related journals, so that others can learn from the study. Also, the researcher will give presentations at health related conferences to disseminate the information and results of this research study. When using the quotation of what you said, the researcher will be careful to ensure that it is not possible for anyone to identify you as a participant in any reports, papers or presentations. If you participate in the study, the researcher will send to you a summary of the results when the study complete.

427 Who has reviewed the research project? This study will be reviewed by the supervisors of this study at The University of Manchester, The University of Manchester Research Ethics Committee (UREC) and the Ministry of Health ethical committee in Oman.

What if I want to make a complaint?

Please feel free to discuss this information with others before deciding whether or not to take part. You can also contact the research team directly (details above), if something is unclear. If you would like to take part. If you agree to take part in an interview, I will contact you to arrange a time, venue and date that is best for you. The interview can take place in your house or at your working place.

Thank you for taking the time to read this information.

428 Appendix 38: Consent Form for Postnatal Mothers/ Observation (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016 CONSENT FORM Postnatal Mothers: Observation

Please read and put your initials next to the statements below and then sign the bottom of the form where it says ‘name of participant’.

PLEASE RESPOND TO ALL OF THESE QUESTIONS Please initial box

1. I confirm that I have read and understand the information sheet dated May c 2016 (version 1) for the above study and have had the opportunity to ask a member of the research team any questions I may have about the study. 2. I understand that my participation is voluntary and that I am free to c withdraw at any time, without giving any reason.

3. I understand that I cannot withdraw collected data when the researcher c reaches the time of anonymising transcriptions or at the time of the publication. I agree to this. 4. I am aware that the observation will be recorded by note taken (no one else, c apart from the researchers, will have access to it), which will be stored in a secure location. I agree to this. 5. I am aware that the observation will be focused on the practice of the c midwives in the healthcare institutions. I agree to this.

6. I am aware that the data will be stored in a secure location and destroyed by c the researchers once the study has been written up. I agree to this. I agree to take part in this study ______Name of Participant Signature Date ______Lead Researcher Signature Date

You will have a copy of this form to keep. A further copy will be stored in the researcher’s site file.

Lead Researcher: Zalikha Al-Marzouqi, School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. Email: [email protected]

429 Appendix 39: Healthcare Professionals Leaflet (Clinical Observation)

Appendix 41: Healthcare Professionals Observation Leaﬂet

Would you like to share your clinical practice on how to support breastfeeding in the health institutions?

I am researching midwives’ and nurses’ clinical practice how you are supporting breastfeeding and I am keen to observe your practice on supporting breastfeeding.

Soon, I will be asking volunteers.

If you want any further information, Please contact the gatekeepers on ofﬁce telephone number: ??? Extension: ???

430 Appendix 40: PIS for Healthcare Professionals Observation (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study Version 1, May 2016

Participant Information Sheet

Healthcare Professionals: Clinical Observation

You are being invited to take part in a study exploring the views of post-natal mothers who are breastfeeding. We would like to observe you while you are providing care to post-natal mothers in your working area. Please, read carefully the following information about the study, ask me any questions you like and feel free to discuss with your family and take the time to decide whether or not you want to participate in the study.

What is the purpose of the study? This study will investigate mothers experience on breastfeeding and as one of midwives who provide care to those group of women, I would like to observe how you support the practice of breastfeeding in the healthcare institutions in North Batinah Governorate. It is anticipated that information from this research study will help the Ministry of Health in Oman to improve care in the future for women who are breastfeeding.

Why have I been chosen? You have been chosen because you are a midwife who is providing care to post-natal mothers in the Ministry of Health institutions in North Batinah Governorate.

What would I be asked to do if I took part? If you agree to be involved in this study, you will be asked to sign two copies of the consent form, one will be given to you and the other one will be kept with the researcher. During your call to the researcher, together will agree on time for observation. The observation will be conducted once during your work in healthcare institution for 20-30 minutes. During observation, the researcher will take notes.

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What happens if I do not want to take part or if I change my mind? It is according to your decision whether or not to participate in this study. Even if you signed the consent form to take part, you are still free to withdraw at any time and without giving any reason. However, if you participated you cannot withdraw collected data when the researcher reaches the time of anonymising transcriptions or at the time of the publication.

Will I be paid for participating in the research? There will be no payment for participating in the research.

What is the duration of the research? The total duration of the research is three years. Your involvement will be taking part in one observation which will last approximately for 20-30 minutes.

Where will the research be conducted? The research will be conducted in the Ministry of Health institutions in North Batinah Governorate at your working area.

Will the outcomes of the research be published? The researcher may publish the research study in related journals, so that others can learn from the study. Also, the researcher will give presentations at health related conferences to disseminate the information and results of this research study. When using the quotation of what you said, the researcher will be careful to ensure that it is not possible for anyone to identify you as a participant in any reports, papers or presentations. If you participate in the study, the researcher will send to you a summary of the results when the study complete.

432 What if something goes wrong? The researcher does not anticipate that participating in this study will cause you problems or harms. If, however, you are unhappy or have problems with any aspect of the way that you are treated, you should contact the ethical committee in the ministry of health in Oman at this email [email protected] and phone number 24697551. Also you can contact the lead supervisor of this study who is Professor Dame Tina Lavender at this email [email protected]. Any complaint you make will be taken very seriously. In addition to that, in order to protect you more, the project will be covered by The University of Manchester’s insurance for research studies. If any problems or issues arise that you do not want to raise with the research team, you will be able to contact the University Research Office at this number +44(0)161 275 7583. What if I want to make a complaint?

Please feel free to discuss this information with others before deciding whether or not to take part. You can also contact the research team directly (details above), if something is unclear. If you agree to take part in an observation, I will contact you to arrange a time that is best for you. The observation will take place at your working place.

Thank you for taking the time to read this information.

433 Appendix 41: Consent Form for Healthcare Professionals/ Observation (English)

Perception of Omani Mothers on Exclusive Breastfeeding: A Grounded Theory Study

Version 1, May 2016

CONSENT FORM Healthcare Professionals: Clinical Observation

Please read and put your initials next to the statements below and then sign the bottom of the form where it says ‘name of participant’.

PLEASE RESPOND TO ALL OF THESE QUESTIONS Please initial box 1. I confirm that I have read and understand the information sheet c dated May 2016 (version 1) for the above study and have had the opportunity to ask a member of the research team any questions I may have about the study. 2. I understand that my participation is voluntary and that I am free to c withdraw at any time, without giving any reason. 3. I understand that I cannot withdraw collected data when the researcher c reaches the time of anonymising transcriptions or at the time of the publication. I agree to this. 4. I am aware that the observation will be recorded by note taken (no one c else, apart from the researchers, will have access to it), which will be stored in a secure location. I agree to this. 5. I agree to the use of my direct quotes in any reports or publications, if c they are used in such a way that I will not be identified.

6. I am aware that the data will be stored in a secure location and destroyed c by the researchers once the study has been written up. I agree to this. I agree to take part in this study ______Name of Participant Signature Date ______Lead Researcher Signature Date

You will have a copy of this form to keep. A further copy will be stored in the researcher’s site file.

Lead Researcher: Zalikha Al-Marzouqi, School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. Email: [email protected]

434 Appendix 42: Breastfeeding Policy in Oman

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Appendix 43: Criteria for Evaluating the Rigour of the Study

Criteria Criteria elements Credibility • Has your research received intimate familiarity with the setting of the topic? • Are the data sufficient to merit your claims? Consider the range, number, and depth of observations contained in the data • Have you made systematic comparisons between observations and between categories? • Do the categories cover a wide range of empirical observations? • Are there strong logical links between the gathered data and your argument and analysis? • Has your research provided enough evidence for your claims to allow the reader to form an independent assessment-and agree with your claims?

Originality • Are your categories fresh? Do they offer new insights? • Does your analysis provide a new conceptual rendering of the data? • What is the social and theoretical significance of this work? • How does your grounded theory challenge, extend , or refine current ideas, concepts, and practices?

Resonance • Do the categories portray the fullness of the studied experience? • Have you revealed both liminal and unstable taken-for-granted meanings? • Have you drawn links between larger collectivises or institutions and individual lives, when the data so indicate? • Does your grounded theory make sense to your participants or people who share their circumstances? Does your analysis offer them deeper insights about their lives and worlds?

Usefulness • Does your analysis offer interpretations that people can use in their everyday worlds? • Do your analytic categories suggest any generic processes? • If so, have you examined these generic processes for tacit implications? • Can the analysis spark further research in other substantive areas? • How does your work contribute to knowledge? how does it contribute to making a better world?

Source: Charmaz (2014): pp. 337-338

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