The aim of this study was to investigate the knowledge level, attitudes and perceptions of Gynecology healthcare professionals in Greece towards breastfeeding with a questionnaire focusing especially on various relative objectives. In fact, this study of the knowledge, attitudes and practices of established Greek healthcare professionals in relation to breastfeeding, by evaluating: their knowledge, their attitudes and perceptions and their education regarding breastfeeding.
In terms of the first theme, most participants supported that their level of knowledge about breastfeeding was moderate at best and could be further improved. Many of them reported that they had hardly received any formal breastfeeding training from their department or school and admitted that their current level of knowledge has been achieved almost entirely by their own personal research and everyday working experience. These findings are on agreement with various studies in other countries where healthcare professionals admitted that they were significant knowledge gaps in their background which made them ill-prepared to counsel breast-feeding mothers (24–30). Most participants lacked knowledge about the safe use of medication from mothers during breastfeeding, something that has been reported by Amir et for Australian healthcare professionals as well (31). Additionally, a significant number lacked knowledge concerning the management of special breastfeeding scenarios such as mastitis development, Hepatitis B or HIV status or high fever appearance, a finding that has also been reported by Brodribb et al for Australian healthcare professionals (32).
However, despite admitting their low knowledge levels, most of the participants stated that they were very confident concerning the management of any breastfeeding related issues in their everyday practice. This high level of confidence was in contrast to other studies where healthcare professionals wondered whether their lack of breastfeeding knowledge could have a negative impact on their ability to handle effectively any breastfeeding related issues (32). This difference could possibly be explained by the fact that most participants in this study were of relative low age. Their age-related enthusiasm and energy combined with their lack of working experience could result in higher levels of confidence compared to those of experienced fully qualified older healthcare professionals that participated in other studies (24–29, 32). In fact, Ahmed et al found that despite Egyptian healthcare students having low knowledge scores and not holding strongly positive attitudes towards breastfeeding, more than 70% of the students indicated they were confident or very confident about their ability to support breastfeeding (33).
In terms of their attitudes and perceptions regarding breastfeeding, most participants generally supported breastfeeding up to 1 year of age followed by those supporting the breastfeeding up to 2 years of age. Furthermore, the vast majority was in favor of public breastfeeding and breastfeeding while returning to work. The same picture has been painted by previous studies evaluating healthcare professionals from other countries around the globe including United States, Mexico, United Kingdom (Ireland, Scotland, England), Iraq, Israel, Taiwan and Australia which revealed very positive attitudes towards breastfeeding (26–30, 34, 35), although one study found that over one third of nursing American students were against public breastfeeding and another reported that all students held this belief (36, 37).
In terms of their education regarding breastfeeding, most participants admitted that basically they have not received any breastfeeding education/training by their departments, or that their education/training was superficial. This was in agreement with Freed et al who reported that only 38% had received any education from their departments about breastfeeding and indicated what little they knew came from other residents and nurses (38). In fact, most participants in this study stated that although having learned basic principles about breastfeeding from their departments, their education was lacking in didactic depth and their training in hands-on experience and that there was definitely room for improvement in their education/training curriculum. This is very much in line with other studies, where healthcare professionals stated that their education and training about breastfeeding was more of superficial instead of being substantial either in theoretical background or technical skills (35, 39).
It has been found that breastfeeding education for healthcare professionals results in greater knowledge, improved use of resources, and a more proactive approach to breastfeeding support and the creation of a breastfeeding-friendly environment (40, 41). A subsequent study confirmed that healthcare professionals’ knowledge was low and their misinformation disturbingly high making the need for the design of educational & training programs that would provide comprehensive education on breastfeeding (42). Another study revealed a reported low level of confidence in their skills underlying the need for the need for didactic and clinical training in breastfeeding (34).
This study also revealed that healthcare professionals that have previous breastfeeding experience (themselves or their partners) or are willing to breastfeed their newborns are most likely to recommend breastfeeding to other mothers, a finding in agreement with previous studies where it was shown that healthcare professionals with breastfeeding experience had more positive attitudes towards breastfeeding than those without any personal experience (27, 43–45). Also, this study revealed that the vast majority considered that breastfeeding was more convenient and cheaper than formulas whereas in other former studies there was a balance between the convenience of both feeding methods (46). Moreover, it was shown that most healthcare professionals agreed that breastfeeding is far more superior to formula feeding in promoting bonding between the mother and her baby matching the opinion of healthcare professionals from other studies (30, 46, 47). Regarding bonding between the father and his baby, a significant number of the participants (both male and female) stated that the breastfeeding excludes the father from the raising of his child since it basically involves only the mother of the child. This is a finding for which the literature is inconclusive since there are studies that have raised concerns whether breastfeeding might make fathers feel excluded (30) whereas there are other ones where most healthcare professionals (either male or female) totally agree that breastfeeding does not affect the bonding process between the father and his baby (46).
The above results are very interesting and they can assist in developing breastfeeding policies and professional education to support Greek healthcare professionals in this vital role.
It is a well-established fact that breastfeeding is important to infants and their mothers for nutritional, immunologic, psychologic, and other health reasons is an established fact. While all the participating healthcare professionals had positive attitudes towards breastfeeding, they were often lacking in knowledge and training to provide strong support to mothers during their breastfeeding journey. To solve this educational problem, the existing educational curriculum should be improved since as stated by the participants there is definitely room for improvement. To establish breastfeeding and human lactation as an integral part of medical student education, the topic should be included in the present curriculum at the appropriate natural points, whether it is a class on anatomy, physiology, nutrition, endocrinology, women’s health, or infant care, discussing topics such as the properties of breast milk, benefits of breastfeeding for both mother and infant, assessment parameters for effective breastfeeding, maternal support, and achievement of proper latch in a didactic instructional manner (16, 33, 37, 48).
A range of formats and educational strategies can be applied including, apart from the didactic lecture style, simulation and clinical placement, evidence-based seminar updates (49) with case studies (50) in conjunction with, or perhaps replacing, didactic classroom lectures. Specialized training workshops and seminars have been characterized as useful as well (48–50). Increasingly online education can be applied as well. In fact, studies have shown that the additional online module improved undergraduate nursing students’ learning as well as their confidence in the clinical setting (51).
The program should be taught by healthcare professionals who are qualified faculty members recognized by their colleagues and certified by specialty examining boards. The classes should be part of the total curriculum and not something a student can elect to do only in the last year of the program, when most of the assignments are by electives since it is highly unlikely that graduate physicians or nurses in practice will attend a teaching day exclusively on breastfeeding which may not serve their educational needs when they are also responsible for keeping up to date on the constant flow of advancements in every field of Modern Medicine. However, what needs to be established here is that much remains to be learned in Modern Medicine, and lactation should be part of it (42).
Practical experience should be provided through clinical placement at a hospital based maternity unit where nursing and medical students can have opportunities to observe and interact with lactation consultants, nurses and other healthcare professionals as they provided breastfeeding support to new mothers (16, 33, 37, 52). Providing students with opportunities to practice breastfeeding management skills before actually caring for clients in a clinical setting may increase confidence (33).
The ideal educational curriculum should ensure that all participating healthcare professionals will receive accurate breastfeeding education including both the knowledge and skills to support women to breastfeed (53–55). For facility personnel whose role may involve educating, advising or assisting women in relation to breastfeeding, they should have a minimum of 20 hours of breastfeeding education, consisting of at least 8 hours theoretical education and at least 3 hours relevant supervised clinical experience on breastfeeding (53–55). The education program may include various delivery options such as workshops, face-to-face or online education (Yang et al., 2018). Two intervention studies were based on the BFHI 20hr module but both adapted this by either reducing the content to 16 h online (56) or reducing to 10 h with a significant clinical component of 8 weeks (57). Both had positive effects on students’ breastfeeding knowledge.
Hospital administrative, medical, nursing, and nutrition staff should establish a strategy that promotes and supports breastfeeding through the formation of an interdisciplinary team responsible for the implementation of hospital policies and provision of ongoing educational activities. There is a need for training which can specifically address feelings of hopelessness and powerlessness in staff with regards the positive impact they can have on breastfeeding behavior, and for policy makers to acknowledge and address the ambivalence that exists regarding some current promotion practices (23).
Breastfeeding topics should become part of a well-rounded continuing education program that includes a number of other important issues, such as infectious diseases, endocrine problems, growth, development, and perinatology. When breastfeeding is included in programs on infant nutrition and presented by a certified healthcare professional, it will gain the status it needs.
Expert teams, well-organized educational programs and advanced computing could contribute to the personnel’s harmonization with the various breastfeeding objectives in order to create a “breastfeeding-friendly” social environment.