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Working at the interface between the art and science of breastfeeding: A qualitative study of International Board Certified Lactation Consultants’ experiences. Sarah Jane Brown A thesis submitted in fulfilment of the requirements of Bournemouth University for the degree of Doctor of Philosophy September 2012 Bournemouth University This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with its author and due acknowledgment must always be made of the use of any material contained in, or derived from, this thesis. 2 Sarah Jane Brown: Working at the interface between the art and science of breastfeeding: A qualitative study of International Board Certified Lactation Consultants’ experiences. Abstract Since 1985 a specialist breastfeeding practitioner, an International Board Certified Lactation Consultant (IBCLC), has been in existence. European and global recommendations propose that IBCLCs are employed within health services to support breastfeeding initiatives, however, the research- based evidence is restricted and did not include any description of the experiences of practitioners. The aim of this study was to describe the experiences of IBCLCs in England and in the process understand some of the enablers and barriers of their role. Data was collected through narrative accounts from twelve IBCLCs who worked in the north of England. The first interview asked practitioners to narrate accounts of how they became and practiced as IBCLCs and the second interview, six months later, sought further elucidation on topics that were found to be common experiences to all practitioners. The narrative accounts were analysed through a social constructionist framework where descriptions were drawn into categories, then themes. The four themes were identified as; centred on breastfeeding; developing a breastfeeding practice; chip, chipping away at the breastfeeding practice coalface and maintaining a balance within a professional practice. The IBCLCs described seeking a niche in practice from which they could work with the necessary freedom and autonomy to meet the needs of the breastfeeding dyad. The IBCLCs demonstrated a passion and a woman-centred expertise which led them to being seen as breastfeeding champions. All of the participants extended their role into teaching and managing change in breastfeeding practice but the participants felt underprepared and not well 3 supported for such a role. While the IBCLC qualification provided the professional qualification the participants’ sought, the study identified issues that needed further consideration. 4 List of contents Abstract 3 List of contents 5 List of tables 9 Acknowledgements 10 Abbreviations and Definitions 11 Chapter One : Rationale and Introduction 1.1. Rationale for the study 15 1.2. Introduction 16 Chapter Two :The development of a professional role in breastfeeding practice 2.1. Introduction 26 2.2. The IBCLC role 26 2.3. Professionalising breastfeeding practice 27 2.4. The development and possible issues with the IBCLC role 30 2.5. Assessing the impact of the IBCLC role 35 2.6. Working with an international qualification 38 2.7. Global frameworks that support and protect breastfeeding 40 2.7.1. WHO International Code of Marketing Breast-Milk 41 Substitutes (1981) 2.7.2. The Innocenti Declaration (1990-2005) 42 2.7.3. The WHO and UNICEF Baby Friendly Initiative (1991) 43 2.8. Implementing change in breastfeeding practice 45 2.9. Defining the role of IBCLCs 45 2.10. Conclusions on being an IBCLC 48 2.11. Aims and objectives of the study 49 Chapter Three: Finding a way to explore IBCLC’s experiences 3.1. Introduction 51 3.2. My standpoint as the researcher 51 3.2.1. Understanding the tensions of becoming a researcher 53 3.3. Setting the research framework 53 3.3.1. Choosing narratives to hear IBCLCs accounts 54 of practice 3.3.2. The use of a social constructionism framework 56 3.3.3. Questioning the need for a woman-centred 57 perspective for the study 3.3.4. Practice and power 57 3.4. Data collection 59 3.4.1. Sample and recruitment 59 3.4.2. Interviewing IBCLCs 62 5 3.4.3. Reflections on using research interviews 64 3.5. Data management and analysis 67 3.5.1. The analytical framework 67 3.5.2. Reflections on the methodology and analysis 72 3.6. Consideration of reliability, validity and trustworthiness 73 in the study’s findings 3.7. Ethical considerations 74 3.7.1. Procedural ethics 75 3.7.2. Ethics in practice 79 3.7.3. Relational ethics 81 3.8. Conclusions to the chapter 82 Chapter Four: Centred on breastfeeding 4.1. Introduction 83 4.2. Personal experiences of breastfeeding 83 4.3. A passion for breastfeeding 89 4.4. Working with breastfeeding women: a continuum of life 94 4.5. Responsive mothering through breastfeeding 95 4.6. Considering a centeredness on breastfeeding 102 Chapter Five: Developing a professional breastfeeding practice 5.1. Introduction 103 5.2. Finding a professional pathway 103 5.2.1. Finding out about becoming an IBCLC 104 5.2.2. Finding gaps in breastfeeding knowledge 105 5.3. Becoming an IBCLC 109 5.3.1. Developing a breastfeeding practice 111 5.3.2. Lactation consultant or IBCLC: using a title 114 5.4. Location of IBCLC practice 116 5.4.1. Working in the NHS 116 5.4.2. Working in private practice 121 5.4.3. Working as a volunteer 124 5.5. Considering the development of a professional 126 breastfeeding practice Chapter Six: Chip, chipping away working at the breastfeeding coalface 6.1. Introduction 128 6.2. Working with health professionals, noticing the gaps 129 6.3. IBCLCs as local breastfeeding champions 134 6.4. Working with health professionals 137 6.5. Learning to teach away from the clinical coalface 141 6.5.1. Education or training a confusion in descriptions 147 6.5.2. Facilitating learning to support the Baby Friendly 148 Initiative 6.5.3. IBCLC involvement in teaching medical staff 152 6.5.4. Teaching breastfeeding peer supporters 153 6 6.6. Supporting IBCLCs to teach 156 6.7. Managing change in breastfeeding practice 158 6.8. Conclusion to the chapter 164 Chapter Seven: Maintaining a balance with professional practice 7.1. Introduction 167 7.2. Staying in a meaningful professional breastfeeding practice 167 7.2.1. Illustrating a sensitivity in practice 168 7.2.2. Exploring an empathetic understanding of right 171 brain learning 7.3. Practising within the NHS 177 7.3.1. Perceptions of other health professionals 177 7.3.2. Keeping the breastfeeding plate spinning 177 7.3.3. Protecting breastfeeding practice 180 7.4. Listening to narratives of stress and frustration 182 7.5. Sources of support 186 7.5.1. Support from family and friends 186 7.5.2. Managerial support 187 7.5.3. Support for professional practice 189 7.6. Considering balancing breastfeeding practice. 192 Chapter Eight: Enablers, barriers and recommendations identified from the study’s findings 8.1. Introduction 195 8.2. Participants articulating for breastfeeding but not for their 197 IBCLC role 8.2.1. Promoting the IBCLC role 199 8.2.2. Developing skills associated with being an IBCLC 202 8.2.3. Working with other organisations that support 204 breastfeeding women 8.3. Support for IBCLCs 204 8.4. IBCLC professional recognition and accountability 206 8.5. Looking at different practice frameworks for IBCLCs. 208 8.5.1. Moving into Public Health 208 8.5.2. IBCLCs and social enterprise initiatives 209 8.5.3. Working with other health professionals as an 210 IBCLC in the health service 8.6. Recommendations for the promotion and support of 211 IBCLCs in England 8.7. Conclusions on the experiences of IBCLCs 214 7 Chapter Nine : Reflections on the study and recommendations for further research. 9.1. Introduction 218 9.2. My reflective description of the participants 218 9.3. Strengths, limitations and conclusions of the study 219 9.4. Recommendations for further research on the role of 223 IBCLCs References 226 Appendices Appendix 1: Research involving IBCLCs 1989 -2009 1 Appendix 2: Reflexive questioning framework 18 Appendix 3: Examples of research diary entries 19 Appendix 4: Letters to local recruiter and recruit IBCLCs 21 Appendix 5: Information to the participants about the second 31 Interview Appendix 6: Transcription symbols 36 Appendix 7: Bournemouth University ethical review 37 Appendix 8: NHS Regional Ethical review 39 Appendix 9: NHS Local Governance Ethical Approval 45 8 List of Tables Table 1: IBCLCs recruited to the study 61 Table 2: The arrangement of categories into themes 69 Table 3: The analytical framework of the narrative 70 accounts which were set within a social constructionist framework. Table 4: Circles of reflection and reflexivity illustrating 71 the interaction between the questioning of one to five in enabling the analysis of the IBCLCs narratives. Table 5: The harmonious and obsessive passion for 92 breastfeeding scale Table 6: Diagram illustrating how the IBCLCs practised 196 centring their care around the breastfeeding dyad. Table 7: A comparison between the six descriptive aspects 201 of an IBCLC in the ILCA (2010) leaflet (A) and from this study (B). Table 8: IBCLC Code of Professional Conduct Principles 208 (A/IBLCE 2010) and the proposed changes (B/IBLCE 2011f). 9 Acknowledgements I am very grateful for the encouragement and guidance that I received from my supervisors Dr Jen Leamon and Dr Kath Ryan while undertaking this study. Their patience and wisdom helped to keep me focused when diversions tempted me away from the main objectives of the study. I would also like to thank Dr Moira Walker and Dr Kate Galvin, who both offered their supervisory support to me at different times during the research.

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