A critical analysis of the content of the tools that measure breast-feeding interaction

A critical analysis of the content of the tools that measure breastfeeding interaction Victoria Hall Moran, Kate Dinwoodie, Ros Bramwell and Fiona Dykes Objective: to undertake a critical analysis of the content of six tools, which have been designed to evaluate the breast-feeding interaction. Design: the tools are viewed as discourses and are examined in terms of the insight they give into the assumptions about and attitudes towards breast-feeding inherent in the authors who have produced them. Findings: the ¢ndings indicate that there is little agreement between the existing breastfeeding assessment tools as to how to measure a successful breast feed and that the tools appear to place insu⁄cient reliance upon the research evidence related to lactation. Key conclusions: the lack of commonality between evaluation tools appears to re£ect a prevailing inconsistency in the advice given by health workers to breast-feeding mothers. Reports of their unreliability may be indicative of the problems inherent when attempting to impose a biomedical model upon an intrinsically natural interaction. Implications for practice: it is suggested that, if evaluations of the breast-feeding interaction are to be useful, a tool which places greater emphasis on the research evidence is called for. Otherwise, given the limitations of such tools, their use may actively hinder the establishment of successful breast feeding. & 2000 Harcourt Publishers Ltd

Victoria Hall Moran BSc, PhD, Research Fellow Kate Dinwoodie MA, BA, RM, RGN, Senior Lecturer in Midwifery Ros Bramwell BSc, PhD, CPsychol, Principal Lecturer in Reproductive and Infant Studies Fiona Dykes MA, RM, RGN, ADM, Senior Lecturer in Midwifery, Department of Midwifery Studies, University of Central Lancashire, Preston PR1 2HE, UK. (Correspondence to VHM) Received 30 June 1999 Revised 22 December 1999 Accepted 9 March 2000 Published online 11 August 2000

INTRODUCTION The promotion and advancement of successful breast feeding have long been a major focus for health-care providers and researchers. As a result a number of tools have been developed in recent years in an attempt to enable health workers and parents to assess successful breast-feeding interactions. The potential benefits of a tool that adequately quantifies successful breast feeding are manifold: parents would feel reassured that they are providing the best care for their baby; it would enable health workers to predict breastfeeding problems and follow-up care to be carried out; and would provide a valuable commodity for quality assurance measures for health managers (Riordan & Koehn 1997). Despite numerous attempts, however, there remains little consistency amongst researchers as to what constitutes successful breast feeding and, as a consequence, the existing tools reveal little Midwifery (2000) 16, 260 ^268 & 2000 Harcourt Publishers Ltd doi:10.1054/midw.2000.0216, available online at http://www.idealibrary.com on

commonality. The tools focus on different aspects of baby and maternal behaviours during breast-feeding interactions, such as the absence of breast feeding problems, maternal satisfaction, duration of the feed or symptoms of dehydration in the baby. The authors of all of the tools, however, state that they indicate the efficacy of the feeding observed and many use numerical scores to quantify this. The aim of the present review was to compare and contrast the existing tools, identified after an extensive review of the literature, which seek to evaluate the breast-feeding behaviour of healthy term babies and their interaction with their mothers, examining common themes and investigating their strengths and weaknesses. The tools examined are for use by health professionals and/or parents. There also exist tools which specifically determine breast-feeding satisfaction (Maternal Breastfeeding Evaluation Scale developed by Leff et al. 1994), breast-feeding behaviours of

A critical analysis of the tools that measure breast-feeding interaction

preterm babies (e.g. the Preterm Infant Breastfeeding Behaviour Scale by Nyqvist et al. 1996) and tools which are designed for research purposes (e.g. the Potential Early Breastfeeding Problem Tool by Kearney et al. 1990). This analysis treats the tools as ‘texts’ to be subjected to a discourse analysis. This takes a multi-disciplinary, social constructionist approach to the tools as ‘social artefacts’ which produce and reproduce an understanding of, in this case, what constitutes a ‘good’ breast-feeding interaction (see e.g. Potter 1996). Discourse analysis is actually used to describe a variety of approaches, but Gill (1996) suggests it is helpful to think of the analysis as being made up of two related phases: first, the search for pattern (both differences and consistency); and second, formulation of tentative hypotheses regarding the functions of particular features of the discourse. Potter (1996) argues that discourse analysis does not preclude quantification, but makes clear that this approach is not consistent with the testing of hypotheses (and hence inferential statistics). Gill (1996) points out that, with this approach ‘the same text can be interrogated in a whole range of different ways by discourse analysts’ (p. 144). The individual perspectives and approaches of the researchers are, of course, very relevant within such an approach. This analysis was undertaken by a multi-disciplinary team which included a physiologist, two midwives and a health psychologist, all of whom were active in researching aspects of breast feeding.

Background to the breast-feeding tools The Infant Breast Feeding Assessment Tool (IBFAT) (Matthews 1988) was developed to be used by mothers, midwives and maternity nurses as a tool to assess and measure ‘infant breastfeeding competence’ (p. 154). The tool measures four components of baby breast-feeding behaviour that the author asserts ‘represent the major components of infant breast feeding behaviour’ (Matthews 1988, p. 154). These are (i) readiness to feed, (ii) rooting, (iii) fixing, and (iv) sucking. A score (0–3) is assigned to each of the four components. A total score can range from 0 to 12, the latter representing vigorous and effective suckling. The tool also measures the mother’s perception of, and satisfaction with, the feeding. Inter-rater reliability has been quoted by the author as 91%. The LATCH assessment tool (Jensen et al. 1994) is a breast-feeding ‘charting’ system, designed for use by health professionals, which focuses on the breast-feeding dyad. The stated purpose of the tool was to (i) provide a systematic method for gathering information about individual breast-feeding sessions, asses-

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sing both maternal and baby variables; (ii) define and prioritise areas of needed intervention; and (iii) serve as a communication tool amongst professional caregivers. The authors aimed to move away from the more subjective assessments of the ‘well/fair/poor’ system by using an Apgartype numerical score (0–2) to rate the ‘five key components of breast feeding’ (Jensen et al. 1994, p. 32). The acronym ‘LATCH’ represents the following sections: ‘L’ is how well the baby latches onto the breast; ‘A’ is the amount of audible swallowing; ‘T’ is the mother’s nipple type; ‘C’ is the mother’s level of comfort; and ‘H’ is amount of help the mother needs to hold her baby to the breast. The Mother-Baby Assessment Tool (MBA) was developed by Mulford (1992) to enable health professionals to document systematic observations of breast feeding and to assess the effectiveness of individual feeding sessions. The focus of the tool is to enable health workers to assess the progress of the mother and baby as they learn to breast feed and so for each step there is a mother and baby behaviour to assess. The breast-feeding process is divided into five steps: (i) signalling, (ii) positioning, (iii) fixing, (iv) milk transfer, and (v) ending. The tool uses a similar scoring method to the Apgar score with maximum scores of 5 for maternal behaviours and 5 for baby behaviour indicating, highly effective feeding. The Systematic Assessment of the Infant at Breast (SAIB) is an evaluation tool designed to be used by a health worker (Shrago & Bocar 1990). The tool aims to assess the baby’s ‘contribution to breast feeding’ (p. 209), that is the effective removal of milk from the breasts, thereby contributing to successful breast feeding. The tool consists of four components: alignment, areolar grasp, areolar compression and audible swallowing, which the authors state are important to make an accurate breast-feeding assessment. The authors state that use of the tool would enable early recognition of breast-feeding problems and aid the initiation of appropriate interventions. The B-R-E-A-S-T-Feed Observation Form is a tool developed for use by health professionals carrying out the WHO/UNICEF Breast-feeding Management course (WHO/UNICEF 1997). Participants on the course are encouraged to use the form when assessing breast-feeding interactions during their clinical practice. The form is divided into six sections: body position, responses, emotional bonding, anatomy, suckling, and time spent suckling. The form consists of two columns, one indicating signs of a successful breast feed and the other giving the opposing signs. If the health worker records only positive signs this indicates that the breast feed is probably going well. If some negative signs are

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observed this indicates that there may be problems and follow-up action required. The Breastfeeding Evaluation and Education Tool (BEET) tool (Tobin 1996) is a tool designed for use by parents and health professionals. New parents are encouraged to use the tool to assess ‘the adequacy of their baby’s breastfeeding’ (p. 47). Emphasis was placed upon developing a concise and easy to read tool that could be taken home with parents if required. The tool was also developed with the intention of serving as a teaching tool for health-care providers, both to teach breast-feeding techniques to mothers and to provide in-service education of other healthcare professionals. The tool consists of eight sections (feedings, position, latch, suck, milk flow, intake, output, and weight gain) and serves as an information sheet providing parents either with reassurance or motivation to seek assistance.

Evaluation and comparison of breastfeeding tools The analysis of the tools comprised three stages. First, the main part of the analysis focused on the content of the tools. Next, an examination was made of the stated functions of the tools. Finally, the papers which presented the development of the tools were examined to determine what evidence was cited for the stated tool elements.

Analysis of tool content The similarities and differences among the six breast-feeding evaluation tools are presented in Table 1, which provides the reader with a clear visual overview of each of the tools. To facilitate the comparison eight themes were identified: (i) baby’s behaviour, (ii) mother’s behaviour, (iii) positioning, (iv) attachment, (v) effective feeding, (vi) health of the breast, (vii) health of the baby, and (viii) mother’s experience. The tools were then rigorously scrutinised and each breastfeeding item from each tool was assigned to the appropriate category following the guidelines for content analysis set out in Jones (1996). The number of items present in each of the tools for the eight themed categories is shown in Figure 1. In order to further analyse the discourse, each category will be discussed individually.

Baby’s behaviour Of the six tools, the MBA and BREAST placed the most emphasis upon issues concerning the baby’s behaviour. The most commonly included items were the alertness of the baby and rooting, with only the LATCH and SAIB not using these criteria. As well as incorporating these

items, the MBA and BREAST also both include the spontaneous release of the breast after feeding, the logical conclusion of an effective breast feed.

Mother’s behaviour This section includes both practical skills and emotional responses of the mother to the breastfeeding interaction. Of the six tools the BEET places the most emphasis on the mother’s skills in latching her baby on, incorporating five items from this section in their tool. The BEET covers a combination of skills that the mother uses to support the feeding attempts of her baby, such as a confident hold, stroking the baby’s lips with her nipple and bringing her baby to her breast. Other tools focus upon the mother’s emotional responses, such as the mother holding her baby securely and confidently, frequently touching her baby (BREAST), and watching and listening for her baby’s cues (IBFAT). These tools, rather than making observations about positioning at the breast, emphasise the comfort and confidence of the mother. The tools that do not include any aspect of the mother’s behaviour are the IBFAT and LATCH, together with SAIB which incorporates only one item (‘mother guides the breast’).

Positioning Five of the six tools contain at least two items concerned with positioning of the baby at the breast, with the IBFAT apparently not considering this a central component in the assessment of breast feeding (see Fig. 1). The BEET and BREAST are similar in their use of the following items: baby’s head and body in line (also included in the MBA, LATCH and SAIB tools); baby’s mouth opposite the nipple (the SAIB tool requiring the baby’s head and body to be at breast level); and close body contact between the mother and her baby. However, the mother’s techniques of supporting the baby at the breast are conflicting. The LATCH and BEET tools both emphasise the importance of supporting the baby with pillows, whereas MBA and BREAST assert that it is the mother who should support the baby.

Attachment All tools, excepting IBFAT, include at least three items concerned with attachment of the baby to the breast. The one aspect of attachment that the IBFAT covers is the time taken for the baby to latch on after being placed at the breast (a question, it should be noted, that no other tool asks). The MBA and LATCH tools both include some vital aspects of attachment but appear to

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Table 1 Content analysis of six breast-feeding assessment tools IBFAT BABY’S BEHAVIOUR Alertness of baby to feed Did the baby need any stimulation to feed? Rooting for breast Signalling readiness to feed Baby explores breast with tongue Baby releases breast spontaneously after feed Baby satiated after feed Baby is relaxed

H H H

H1

H H

H H1

BREAST

SAIB

H H H

H H H

H

H H

H H H H H

H

H3 H3

H2 H2 H2 H2

H H H H H

H3

H H H H

H H H

H

H H

H H H H H

H H

H H H H H

H H

H H

H

H

H

H H H

H H H H

H H H H H

H H H H H H H

HEALTH OF THE BREAST Nipple type Signs/absence of trauma to nipple/breast Fullness of breasts (e.g. engorged, hard, full/f|lling, soft)

H H

H H

H H H

HEALTH OF THE BABY Healthy baby (e.g. alert, active) Baby’s skin is supple Inside of baby’s mouth is pink and moist Soft spot at top of baby’s head is level (not sunken) Properties of urine: colour, frequency amount Bowel movement: colour, consistency, frequency, amount Weight gain MOTHER’S EXPERIENCE Ask mother how she feels about way the baby fed Ask mother how her breasts feel Mother feels strong suction Ask mother if she experiences milk transfer

BEET

H

POSITIONING Does mother need assistance to hold baby correctly? Baby’s head and body in line Baby’s mouth opposite nipple Close body contact between baby and mother Baby facing mother Pillows support baby Mother supports baby Baby’s head and body at breast level

EFFECTIVE FEEDING How well did the baby suck? Jaw movement Full/rounded cheeks Rapid sucking initially Rhythmic sucking Audible swallowing Signs of milk release (e.g. breast milk seen) T|me spent feeding

LATCH

H H

MOTHER’S BEHAVIOUR Mother watches and listens for baby’s cues Mother brings baby to breast Secure conf|dent hold of baby Baby touched a lot by mother Mother relaxed and comfortable Mother strokes baby’s lips with nipple Mother supports/guides breast

ATTACHMENT T|me taken for baby to latch on after placed at breast Does baby stay attached to the breast during feed? Position of baby’s mouth over areola Position of baby’s tongue Baby opens mouth wide Lower lip turned outwards on breast Complete seal and strong vacuum formed by baby’s mouth Baby’s chin touching breast T|p of baby’s nose touching breast

MBA

H

H H H H H

H H H

H H H H H H H H H H

4

H H H5

IBFAT: Infant Breast-feeding Assessment Tool (Matthews 1988); MBA: Mother-Baby Assessment Tool (Mulford 1992); LATCH: ‘LATCH Assessment Tool ( Jensen et al.1994); BEET: Breast-feeding Evaluation and EducationTool (Tobin 1996); BREAST: B-R-E-AS-T-feed Observation Form (BFI Training Course); SAIB:Systematic Assessment of the Infant at Breast (Shrago & Bocar 1990) 1

Baby gives readiness cues: stirring, alertness, rooting, sucking, hand-to-mouth, vocal cues, cry. Correctly is described as the breast-feeding baby’s body should be £exed and exhibit no muscular rigidity. The head should be aligned with the trunk, facing the breast and not turned laterally or hyperextended. The mother should support her breast with a cupped hand. Pillows are used to support the baby’s body at breast level. 3 Mother holds baby in good alignment within latch-on range of nipple. Baby’s body is slightly £exed, entire ventral surface facing mother’s body. Baby’s head and shoulders are supported. 4 Mother reports feeling any of the following: thirst, uterine cramps, increased lochia, breast ache or tingling, relaxation, sleepiness. Milk leaks from opposite breast. 5 Mother feels uterine cramps, thirst and sleepiness 2

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Fig. 1 The number of items present in eight themed categories for each breast-feeding evaluation tool.

miss other equally important details (see Table 1), and do not appear to follow the physiological sequence of events that occur when the baby latches onto the breast. This continuum is revealed more fully in the BEET and BREAST, both including signs, such as baby opens mouth wide, lower lip turned outwards on the breast, and baby’s chin touching the breast.

following items important: baby has full or rounded cheeks (not MBA) and displays rhythmic sucking and audible swallowing. Another commonly included item was observing for signs of milk release, such as the visibility of breast milk. The devisors of the BREAST tool alone considered it important to record the length of the feed.

E¡ective feeding

Health of the mother’s breast(s)

Signs of the baby feeding effectively appeared to be the most important for assessing breastfeeding success by all tools. Again the one exception was the IBFAT, which asks ‘how well did the baby suck?’, a question not considered by the other tools. The other tools considered the

Neither the IBFAT nor SAIB tools included items about the health of the mother’s breast. The remaining tools included signs of potential breast-feeding problems, i.e. signs of trauma to the nipple and/or breast (not BEET). These signs are particularly important indicators since recent

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involved in evaluating such subjective feelings, particularly when placed within the framework of these objective assessment tools.

findings have indicated that one of the most commonly stated reasons for the early cessation of breast feeding is nipple trauma (Foster et al. 1997). The LATCH and BREAST also asked about the mother’s nipple type, but both tools failed to provide their reasons for the inclusion. Indeed, the usefulness of this information in predicting breast-feeding success is questionable and it is suggested that placing importance upon such an observation may instil a sense of inadequacy in the mother.

Function of the tools The stated functions of the tools are summarised in Table 2. Whilst the tools all purport to assess the breast-feeding interaction, the tools differ in their target outcomes. All the tools purport to ‘assess’ or ‘chart’ and are also for use by health professionals. Only two, however, are for use by ‘new parents’ (BEET) or mothers (IBFAT). Some tools are designed to assist in the teaching and learning of breast feeding, either by directing parent education (MBA, SAIB, BEET) or teaching health professionals (BREAST). The IBFAT and BEET specifically assess the baby’s breast-feeding behaviour, whereas the MBA assesses breast feeding as a mutual effort of the mother and her baby.

Health of the baby It is noteworthy that the BEET is the only tool to include items in this category, incorporating seven separate items concerned with the health of the baby into their tool (see Fig. 1). Upon closer inspection, however, almost all the items are concerned with observing for signs of dehydration (for example, observing the baby’s mouth, her/his bowel movements and properties of her/his urine). Other items ensure that the baby is progressing well (‘healthy alert baby’) and seek confirmation that the baby is being well nourished (assessing weight gain).

Evidence cited relating to development of tools A simple content analysis of the evidence cited in the papers which present the tools was undertaken, noting the numbers of sources cited and the nature of those sources (this was not possible in the case of the BREAST as there is no published information on the development of this tool). The number of references cited for each of the stated elements of the tools is presented in Table 3. It can be noted that the tools do not always link the research evidence directly to the development of their tools. Furthermore, the quality of the evidence on which the tools are purported to be based is mixed. Some authors rely heavily on text book sources (e.g. the LATCH tool) rather than current empirical evidence, perhaps reflecting a lack of availability of relevant research.

Mother’s experience This section is concerned with asking the mother how she feels about the breast-feeding experience. Questions asked are ‘how does she feel about the way the baby fed?’ (IBFAT), ‘how do her breasts feel?’(MBA and LATCH), if she feels a ‘strong suction’ (BEET) and if she feels ‘symptoms of milk transfer’ (MBA and BEET). Neither the BREAST nor SAIB tools include items of this nature. The experience of the mother is undoubtedly important to her continuance and maintenance of successful breast feeding, so it is perhaps surprising that relatively few questions are asked concerning the issue. Possible reasons for this may include difficulties

Table 2 The function of the breast-feeding evaluation tools Tools

Used for

Used by

When

Where

IBFAT

Assess baby’s breast feeding To assess change over time Charting breast feeding Focus on learning to breast feed as mutual e¡ort Breast feeding charting system and as a communication tool amongst health professionals Assess baby’s breast feeding Teach breast-feeding technique Assessment of breast-feeding technique through observation and as a learning tool for health professionals and mothers Assessment of breast feeding Directing parent education

Mothers Health professionals Health professionals

‘early neonatal period’ *

*

Health professionals

*

Hospital

New parents Health professionals Health professionals

‘early weeks’ *

Home Prenatal breast-feeding class *

Nurses

*

*

MBA LATCH BEET BREAST SAIB

*details not specif|ed

Hospital

266 Midwifery Table 3 Evidence cited relating to the development of the tools Tools

Evidence cited

IBFAT

Four components: readiness to feed (one ref) rooting (no evidence) ¢xing (no evidence) sucking (no evidence) *further evidence discussed in lit review but not directly linked to tool Five ‘steps’ described: no evidence for ‘signalling’ step ‘positioning’ (¢ve refs given but not directly linked with tool) no evidence for ‘¢xing’ step ‘milk transfer’ (one ref) no evidence for ‘ending’ step Five components: sustained latch and rhythmic sucking (four refs) swallowing at breast indicating milk intake (four refs) shape, size and texture of nipple (one ref) mother’s comfort a¡ecting continuation of BF (three refs) positioning (one ref) and help required by mother (one ref) No direct referencing to specif|c BEET items. Resources stated to be used in the development of the tool consisted of four unpublished conference presentations and one peer-reviewed article

MBA

LATCH

BEET BREAST

(No published information on development) SAIB

Five components: alignment (two refs) areolar grasp (¢ve refs) areolar compression (three refs) audible swallowing (no directly linked refs)

DISCUSSION For ease of analysis, eight main areas encompassing the physiology, emotional responses and skills associated with the breast-feeding interaction were identified. The six tools were then scrutinised and each item from each tool was allocated to one of the themes. There appears to be some degree of commonality in the framework used in the tools, each including at least four of the specified areas within their tool. The prime importance of positioning and attachment is evidenced by the shared emphasis of these areas across all the tools. Within these eight areas identified (including positioning and attachment) there is little consistency about which items are deemed most important, suggesting that there is no fundamental standard of effective breast feeding. Indeed, the different authors appear to have opposing interpretations of what constitutes a successful breast feed; for example, the BEET was the only tool to incorporate numerous symptoms of dehydration (see ‘health of the baby’ in Table 1). This raises important questions as to why the tools, whilst all purporting to measure the same phenomena, should include such divergent items. The three themes that all tools incorporate are: ‘baby’s behaviour’, ‘attachment’ and ‘effective feeding’. A further theme used in all tools, aside from the IBFAT, is that of ‘positioning’. This may suggest that in order to develop a more effective tool, these four themes should provide the central foci. These themes also share a secure

grounding in what is presently known about the physiology of lactation and suckling (Woolridge, 1986). For example, the reflexes which the newborn baby possesses to aid feeding are represented in the categories of ‘baby’s behaviour’ and ‘effective feeding’. In addition, the skills that the mother uses to best utilise these reflexes in order to attach her baby successfully onto her breast are communicated in the ‘positioning’ and ‘attachment’ sections.

Evidence basis for tools It is beyond the scope of the present paper to critique the quality of the evidence on which the tools are purported to be based. However, the analysis revealed important variations in the amount of evidence cited for different elements of the tools, and that supporting evidence was not always cited for some, or all, of the specific elements of tools. The content of the tools does not, therefore, appear to have a balanced structure, although the uneven nature of the available evidence may have contributed to this. Perhaps more importantly, available evidence is often ignored. For example, for most tools, the central discourse is the behaviour of the baby at the breast, whilst ignoring the mother’s experience.

Why do we need such a tool? A number of objectives for the applicability of a tool to assess the breast-feeding interaction have

A critical analysis of the tools that measure breast-feeding interaction

been previously stated. Most commonly reported reasons are that such a tool would enable healthcare workers to define areas of needed follow-up care (LATCH, MBA, SAIB) and to facilitate the teaching of breast-feeding techniques to both parents and health workers (LATCH, BEET, BREAST, SAIB). It is suggested that the tools are, indeed, helpful in aiding teaching and detecting problems. They are also useful in that they provide the health professional with a language with which to communicate about the complex breast-feeding interaction. However, when used in isolation they can be of limited use. For instance, a breast feed may ‘score’ well on a breast feeding evaluation form, but if the mother dislikes the experience the interaction could hardly be described as successful. In such a case the evaluation tool would provide us with a score that is very much divorced from context and not a true reflection of the breast-feeding interaction. The tools used as a method for mothers to assess their own breast feeding progress (IBFAT and BEET), unless used to identify specific problems, may even hinder the establishment of successful breast feeding. A mother, for example, may be caused undue concern if her breast feed falls short of the ‘textbook’ standard. The use of numbers to quantify the success of a breast feed (IBFAT, LATCH and MBA) may further instil a feeling of failure in a mother who has not scored ‘adequately’. The use of such tools tend to impose the health professional’s own targets of ‘success’ upon women and may de-legitimise the mother’s sense of achievement if she falls short of that target. The reality, however, is that the mother’s set targets may be very different to that of the health professional and she may feel she is ‘successful’ if she achieves her own objectives. The key determinants of success then, should perhaps centre around the mother achieving her own goals. Finally, the breast-feeding interaction is part of a very unique interpersonal relationship between the mother and baby. This itself makes the process exceedingly difficult to quantify. The scoring and assessment of breast feeding may reflect a need to place breast feeding within a biomedical context. Whilst such a model of breast feeding may be useful, it is by no means all inclusive. Rather, breast feeding is also primarily concerned with the development of a relationship between mother and baby and the complexity of this interaction appears to be under emphasised by all the tools.

CONCLUSIONS Whilst there are a number of tools which claim to effectively evaluate the breast-feeding interac-

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tion, little commonality has been shown to exist between them. This lack of agreement is consistent with reports that some health workers provide inaccurate and conflicting advice to breast-feeding mothers (Garforth & Garcia 1989, Thomson 1989, Chalmers 1991, Rajan 1993, Dykes & Williams 1999). Research has shown that the lack of consistent advice and support in the initial weeks can lead to premature weaning (Buckell & Thompson 1995). It is clear, therefore, that the necessity for consistent advice on breast-feeding matters remains a vital issue in the health care of women and babies. Others have asserted that certain of these tools are neither accurate nor reliable in what they claim to measure. Riordan and Koehen (1997) compared three evaluation tools (the IBFAT, MBA and LATCH) and found them to be inconsistent when evaluating the same breastfeeding experience. The authors suggested that the tools were not sufficiently reliable for clinical use. It may be that such tools are only useful for detecting problems, but cannot be used to evaluate the entire breast-feeding interaction. It is suggested that the lack of consistency and reliability of these tools arises from their attempt to encompass the entire phenomenon, which is perhaps not the most appropriate or accurate way to assess the breast-feeding interaction. Breast feeding is a complex interaction of physiological and psychosocial responses that is unique to the breast-feeding mother and baby, and is one which does not break down readily into very specific defined areas. Recent research has suggested that a more effective means of evaluation may be to measure ‘outcome criteria’ (i.e. breast-feeding problems and breast-feeding satisfaction) (Schlomer et al. 1999, p38). Such a woman-centred approach would be preferable in that the woman’s own criteria for success may then be acknowledged. It is acknowledged that there is a place for breast-feeding evaluation tools in the provision of effective health care, particularly in identifying potential breast-feeding problems. It is clear, however, that the existing tools have some limitations and do not appear to be structured around research-based evidence. Although the evidence does exist, particularly in relation to positioning and attachment (e.g. Woolridge 1986, Righard & Alade 1992), further studies to corroborate the findings would be useful. Further refinements are needed before such tools can be reliably employed as valid measures of effective breast feeding (Riordan & Koehen 1997, Schlomer et al. 1999). Once such a refined tool has been developed, however, one should remain conscious of its inherent limitations. Used in isolation assessment tools are, by their nature, somewhat

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inflexible and prescriptive, and may act to delegitimise a woman’s own interpretation of success. Evaluation tools should not take the place of sensitively-delivered woman-centred individualised care. They could, however, form a useful part of a comprehensive approach to care. Our key aim should be to strive to empower women to become the experts whilst simultaneously providing them with professional support and reassurance (see e.g. Cox & Turnbull 1998). ACKNOWLEDGEMENTS We would like to thank the anonymous reviewer for comments on the first submission of this paper, in particular for pointing out the importance of potential differences in functional aims. REFERENCES Bucknell M, Thompson R 1995 A comparative breastfeeding study in two contrasting areas. Health Visitor 68 63–65 Chalmers JWT 1991 Variations in breast-feeding advice, a telephone survey of community midwives and health visitors. Midwifery 7: 162–166 Cox SG, Turnbull CJ 1998 Developing effective interactions to improve breast-feeding outcomes. Breast feeding Review 6: 11–22 Dykes F, Williams C 1999 ‘Falling by the wayside’ A phenomenological exploration of perceived breast milk inadequacy in lactating women. Midwifery 15: 232–246 Foster K, Lader D, Cheesbrough S 1997 Infant feeding 1995. Social Survey Division of the Office for National Statistics, London Garforth S, Garcia J 1989 Breast feeding policies in practice – ‘No wonder they get confused’. Midwifery 5: 75–83 Gill R 1996 Discourse analysis: practical implementation. In: Richardson JTE (ed.) Handbook of Qualitative Research Methods for Psychology and the Social Sciences. BPS Books, Leicester Jensen D, Wallace S, Kelsay P 1994 LATCH: a breast feeding charting system and documentation tool. Journal of Obstetric, Gynecologic and Neonatal Nursing 19: 209–215

Jones RA 1996 Research Methods in the Social and Behavioural Sciences. Sinaver Associates, Massachusetts Kearney M, Cronenwett L, Barrett J 1990 Breast-feeding problems in the first week postpartum. Nursing Research 39: 90–95 Leff E, Jeffries S, Gagne M 1994 The development of the maternal breastfeeding evaluation scale. Journal of Human Lactation 10: 105–111 Matthews MK 1988 Developing an instrument to assess infant breastfeeding behaviour in the early neonatal period. Midwifery 4: 154–165 Mulford C 1992 the Mother-Baby Assessment (MBA): an ‘apgar score’ for breast feeding. Journal of Human Lactation: 8: 79–82 Nyqvist KH, Rubertsson C, Ewald U et al 1996 Development of the preterm infant breast-feeding behaviour scale (PIBBS): a study of nurse-mother agreement. Journal of Human Lactation 12: 207–219 Potter J 1996 Discourse analysis and contructionist approaches: theoretical background. In: Richardson JTE (ed.) Handbook of qualitative research methods for psychology and the social sciences. BPS Books, Leicester Rajan L 1993 The contribution of professional support, information and consistent correct advice to successful breast feeding. Midwifery 9: 197–209 Righard L, Alade MO 1992 Sucking technique and its effect on success of breast feeding. BIRTH 19: 185–189 Riordan JM, Koehn M 1997 Reliability and validity testing of three breast-feeding assessment tools. Journal of Obstetric, Gynecologic and Neonatal Nursing 26: 181–187 Schlomer JA, Kemmerer J, Twiss JJ 1999 Evaluating the association of two breastfeeding assessment tools with breast-feeding problems and breast-feeding satisfaction. Journal of Human Lactation 15: 35–39 Shrago L, Bocar D 1990 The infant’s contribution to breast feeding. Journal of Obstetric, Gynecologic and Neonatal Nursing 19: 209–215 Thomson AM 1989 Why don’t women breast feed? In: Robinson S, Thomson AM (eds) Midwives, research and childbirth, Vol. 1. Chapman & Hall, London Tobin DL 1996 A breast-feeding evaluation and education tool. Journal of Human Lactation 12: 47–49 Woolridge M 1986 The ‘anatomy’ of infant suckling. Midwifery 2: 164–171 WHO/UNICEF 1997 Breast-feeding management: a modular course. UNICEF, London