Health Promotion in Realtion to a Midwife Essay

In 1946 the World Health Organisation (WHO) defined health as â€Å"a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity†. This definition integrates the main concepts of health and identifies that health can be viewed differently by individuals and groups (Bowden, 2006). Health and well-being are the result of a combination of physical, social, intellectual and emotional factors (Dunkley, 2000a). The concept of health promotion has emerged with the increasing realisation in society that our health is one of our most valuable personal assets, as well as an asset for society (Crafter, 1997). The Health Promotion Agency (2008) describes health promotion as a process enabling people to exert control over the determinants of health and thereby improve their health. Similarly, the WHO identifies that health promotion involves equipping people to have more power, enabling them to make choices in regard to improving their well-being (WHO, 1984). Ewles and Simnett (2003) determine from this that the fundamental elements of health promotion are improving health, empowerment and education. Breastfeeding is the best form of nutrition for infants and so is an important topic in the context of health promotion (Dearling, 1999). Health promotion is not an extended role of the midwife but a core competency. In its Code of Professional Conduct (2008), the Nursing and Midwifery Council (NMC) outlines the role of the midwife to include supporting people in caring for themselves to improve and maintain their health. Midwives must work with others to protect and promote the health and well-being of those in their care (NMC, 2008). Midwives meet and influence individual women and their families on a day-to-day basis, and can make real differences to how those people deal with health issues during their childbearing years and beyond (Crafter, 1997). Davis (2002) points out that every interaction with a woman is an opportunity to improve long-term health as midwives are trusted as authoritative figures in the delivery of health promotion. The Royal College of Midwives’ â€Å"Vision 2000† describes the midwife as a public health practitioner, and relevant models and approaches can enhance the way that midwives deliver care. A health promotion approach can be described as the vehicle used to achieve the desired aim (Dunkley-Bent, 2004). Ewles and Simnett (2003) suggest that health promotion is commonly characterised as having five different approaches: the medical approach; the behaviour change approach; the educational approach; the empowerment approach; and the societal change approach. A summary of these approaches can be found in Appendix One. A model of health promotion seeks to represent reality and demonstrates how these different approaches connect in practice (Dearling, 1999). This assignment applies Beatties (1991) model of health promotion to breastfeeding; analyses the challenges midwives may encounter when promoting breastfeeding and evaluates the effectiveness of the midwife in promoting breastfeeding. Beattie’s (1991) model is appropriate as it provides a structured framework to guide, map and contextualise health promotion intervention related to breastfeeding (Seedhouse, 2003). Beattie’s (1991) model has two dimensions; â€Å"mode of intervention† and â€Å"focus of intervention†. The â€Å"mode of intervention† ranges from authoritative which is top-down and expert-led; to negotiated, which is bottom-up and values individuals autonomy. The â€Å"focus of intervention† ranges from a focus on the individual to a focus on the collective. The model uses these dimensions to generate four strategies for health promotion – health persuasion technique, legislative action, personal counselling and community development (Tonnes and Tilford, 2001). The health persuasion technique utilises the medical and educational approaches to inform women of the research-based health benefits of breastfeeding. This intervention is top-down, directed at individual women and led by midwives as health experts (Perkins et al, 1999). It relies on persuasive tactics to ensure compliance. Being medical-based, it aims to reduce morbidity and reduce premature mortality and is conceptualised around the absence of disease. As midwives do not regard pregnancy and child-birth as states of ill-health, its validity in midwifery care must be questioned (Dunkley, 2000a). The benefits of breastfeeding are well-documented (Appendix Two), however difficulties arise in making this information relevant and personal to each woman. Often, simply giving women ‘information’ makes little difference to them (Dunkley, 2000b). Positive messages about breastfeeding should be evident in the midwife’s practice room (Ewles and Simnett, 2003). Literature and posters that promote breastfeeding can be prominently displayed. All magazines and literature in the waiting room can be examined to ensure that there are no unwanted advertisements or promotions of formula. Health persuasion is based on an assumption that women make rational, conscious decisions about how to feed in response to factual health-related information (Crafter, 2002). Personal attitudes will affect the woman’s decision more than anything; and changing beliefs, values and attitudes is difficult and requires more time, resources and dedication than most midwives have due to over-load of work (Crafter, 1997). Naidoo and Wills (2000) identify four stages in the behaviour-change process, and these can apply to choosing to breastfeed. First, the woman must understand the benefits, accept the relevance of this information to her situation, weigh up the benefits and disadvantages for herself, and finally make her decision on how to feed. Women are advised that if they breastfeed their health and that of their baby will benefit (Piper, 2005). If a woman chooses not to breastfeed, she may experience guilt feelings and start to avoid the midwife, or not share future issues of concern because she is reluctant to receive advice which is inconsistent with her own beliefs and ideas (Battersby, 2000). Non-judgmental support of breastfeeding rather than loaded advice-giving may be more appropriate as it is unethical for the midwife to coerce and persuade women into breastfeeding (Cribb and Duncan, 2002). It is not the role of the midwife to persuade, but to inform (Davis, 2002). The health persuasion technique may be useful in the short-term to raise awareness, but it is unlikely to be effective in itself as it is not enough to simply tell women why breast is best and expect them to choose to breastfeed (Entwistle et al, 2007). There is no opportunity for women to ask questions, follow long conversations or direct the dialogue to areas where they need knowledge (Dunkley, 2000a). Language barriers may also arise, midwives and women may not share the same first language, or women may not understand the medical terms related to the health benefits of breastfeeding (Bright, 1997). Health persuasion can increase the feeling of powerlessness in women; the total opposite of empowerment, which is the core principle of midwifery practice (Royal College of Midwives, 2000). Legislative action attempts to promote breastfeeding at a national level, therefore incorporating the societal-change approach. This is a benevolent, top-down intervention led by professionals in the role of â€Å"custodians† in knowing what will improve the nations’ health (Dunkley, 2000). Legislative action involves making environmental, social and economic changes by policy planning, political action and widespread collaboration with decision makers (Ewles and Simnett, 2003). The Breastfeeding Strategy Group for Northern Ireland was established by the Department of Health and Social Services (DHSS) in 1997 as a result of legislative action to try and improve breastfeeding rates in Northern Ireland. The Innocenti declaration (WHO/UNICEF, 1990) and the WHO/UNICEF Baby Friendly Initiative provide a national framework for best practice to support breastfeeding in maternity units and other healthcare facilities nationwide. Although not based on the actions of individual midwives, midwives can utilise this aspect of health promotion by lobbying power holders through their professional organisations and specialist forums, such as the Royal College of Midwives (RCM), the National Childbirth Trust (NCT) and the Association for Improvements in Maternity Services (AIMS) (Crafter, 2002). These organisations can align themselves together to address issues such as facilities for breastfeeding in public places, marketing of breastfeeding substitutes and improving maternity leave. Legislative action is an effective long-term way of promoting breastfeeding by making breastfeeding socially acceptable and the natural choice for women, thereby positively influencing the concept of breastfeeding within society (Bowden and Manning, 2006). Midwives can help develop strategies for intervention, act as advocates, promote the health of women indirectly and achieve collective improved breastfeeding rates at a level removed from individual interaction (Bowden and Manning, 2006). However, as Acts of Parliament use utilitarian principles they are unlikely to meet equally the needs of everyone (Cribb and Duncan, 2002). Midwives are also faced with a challenge in that the Government is setting targets to be met, which in a way dictates the information to be provided to women (Seedhouse, 2003). Legislative action takes time to achieve its aims, and can be an expensive form of health promotion (Bright, 1997). Community development uses the empowerment approach to enhance breastfeeding support among local communities and bring about local changes relating to breastfeeding facilities. Examples of community development include breastfeeding support groups and Sure Start Initiatives. Peer support in breastfeeding support groups has been found to be more effective in health promotion than the influence of health professionals (Barrowclough, 1997). Midwives can inform women of local groups and initiatives available to them (Barrowclough, 1997). Many women have to sit on public toilet seats or in inappropriate rooms to breastfeed their baby as restaurant proprieters and clientele are often intolerant of breastfeeding. Support groups offer women a comfortable, welcoming place to breastfeed their babies and can campaign locally to change negative attitudes towards breastfeeding (Barrowclough, 1997). Empowering community groups generates norms and social support which will reinforce breastfeeding. The nature of community development encourages autonomy, responsibility and interdependence rather than dependence on a more prescriptive form of care (Piper, 2005). Community development meets women’s needs for emotional and practical care that midwives may be unable to provide due to lack of time, and increases information and support available to breastfeeding mothers (Dunkley-Bent, 2004). Community development can also empower women to determine wider health needs and challenge medical and midwifery services through service user focus groups and participating in patient panels (Dunkley-Bent, 2004). Limitations to community development include lack of government funding for local initiatives, which can be improved through campaigning to raise awareness. Support groups are commonly only accessible to a select group of women, and it is up to midwives to ensure they work to deliver information that reaches all women in their care (Dunkley, 2000a). Midwives are ideally situated to help develop community support networks alongside women and their families (Piper, 2005). Personal counselling involves the empowerment and educationalist approaches. It is a process of active listening and reflection to empower women, based on their current knowledge and behaviour, to become more capable of making genuine informed choices (Dunkley, 2000b) The midwife’s role within this process is purely as a facilitator and enabler rather than an expert, offering guidance and support (Dunkley, 2000b). Being listened to makes individuals feel as though they have some control in planning their lives (Crafter, 2000). Rather than telling women what to do, midwives work with them to identify their needs and empower them to have the skills and confidence to breastfeed (Bright, 1997). Specialised lactation midwives can offer personal counselling if they are available, but in general midwives may have insufficient time to utilise opportunities for personal counselling in the postnatal ward or when women have been discharged back out into the community (RCM, 2002). Discussing the details of skin-to-skin contact and the importance of the first feed antenatally can encourage women to try breastfeeding (RCM, 2002). Many midwives draw on their own experience to support breastfeeding, and while this can sometimes assist good practice, it can cause difficulties as where women report neutral or negative breastfeeding messages, breastfeeding initiation can be affected (Entwistle et al, 2007). If a woman has been given the message that she is worth listening to, and is trusted to make the right decision, she will feel more confident and empowered to breastfeed (RCM, 2000). Time spent helping to establish correct attachment and positioning of the baby at the breast will in the long-term minimise continued dependence on midwifery care (Dunkley-Bent, 2004). An empowered woman would be able to participate more fully in community development, and could help promote breastfeeding by sharing her own positive experience with peers and relatives (Entwistle et al, 2007). The success of this approach is determined by a number of factors including good communication (Crafter, 2002), which can only be achieved with adequate time (Dunkley, 2000b) and the midwife’s personal attitude towards breastfeeding (Entwistle et al, 2007). Antenatal support, good hospital management and subsequent postnatal community visits are all-important components of breast-feeding promotion. Antenatal education and encouragement increases breast-feeding rates and identifies potential problem areas (Barrowclough, 1997). Hospital practices should focus on skin-to-skin contact, rooming-in, early and frequent breast-feeding, skilled support and avoidance of artificial nipples, pacifiers and formula (UNICEF, 2000). Postnatal visits should not be rushed and should include information on support groups available locally. Witnessed breast-feeding is an important part of follow-up because many breastfeeding problems are caused by improper latch-on or positioning that can be detected and corrected (RCM, 2002). Health promotion is an integral part of the midwife’s practice (NMC, 2008). The advantage of using Beattie’s (1991) model in promoting breastfeeding is that it allows midwives to question what actions are really useful in reaching and impacting on women. Beattie’s model helps midwives to review their own actions and critically analyse current methods of promoting breastfeeding (Dunkley-Bent, 2004). Breastfeeding promotion activities must cross each of the four strategies identified within the model if they are to be effective (Piper 2005). Crafter (1997) identifies challenges to implementing these strategies effectively within midwifery practice including time constraints, personal attitudes, inconsistent advice and lack of resources. Midwives must be equipped with the knowledge and skills to participate confidently in the management and promotion of breastfeeding, and thus empower women to breastfeed their babies successfully (Bowden, 2006). An awareness of the wider cultural influences and attitudes to breastfeeding can help midwives to implement effective health promotion strategies (Dunkley, 2000b).