Out of a possible sample size of 327 midwives and 293 student midwives, 253 valid responses were received giving an estimated overall response rate of 40.8%. The hard copy response rate for the three main clinical sites was 24.4%, and most successful in the regional units (Unit C, 75% and Unit B, 44% of all midwifery staff). However, larger numbers of responses were received via the online questionnaire (68% of the total responses), especially from student midwives.

Demographic data

Demographic details of respondents are outlined in Table 2. Data collected showed an almost even split of respondents between midwives and students (51% and 49% respectively).

Table 2 Current roles of participants

Most respondents had qualified as midwives by undertaking or were in the process of completing the direct entry undergraduate BSc Midwifery programme (63.24%) as opposed to the Post General Nursing route. Two hundred and forty-seven (97.6%) respondents identified their place of work.

Participants had a wide range of experience. Among midwives, 52% had been qualified for 10 + years, 14% between 7–9 years, 6% between 4–6 years and 28% were qualified for less than three years.

Among student midwives, all years of education were represented including those at Internship stage and post graduate students undertaking the Higher Diploma Midwifery Programme.

Awareness of Laid-back breastfeeding

The majority of respondents (81.4%) were aware of the LBBF position as a way to help mothers breastfeed their babies.

Awareness of LBBF was greater for midwives and students who had or were undertaking the BSc Midwifery Programme, as opposed to those who had or were undertaking a Higher Diploma postgraduate programme and becoming midwives through the post-nursing route (83.8% vs 77.4%).

Newly qualified midwives (< 3 years) were more aware of the position (92.3%) than those longer qualified (80%), which may reflect the increase of teaching/discussion of laid-back breastfeeding in lactation education over the last decade. (n = 128; χ2 = 7.84; df 1, p = 0.005).

Of the student midwives, 3rd and 4th year students were highly aware of LBBF as a breastfeeding position (96.8% and 91.3% respectively). Surprisingly, more than half of those completing the Higher Diploma postgraduate programme in Midwifery (53.3%) had never heard of LBBF.

Awareness of the LBBF position varied by more than 15% between clinical sites (Table 3). However, a Chi-square test for independence found a low level of evidence between awareness of LBBF and place of work. (n = 201; χ2 = 0.06; df 3, p = 0.896).

Table 3 Awareness of laid-back breastfeeding by clinical siteHelping to establish breastfeeding in practice

Participants were asked to choose the most frequent breastfeeding position that they tended to discuss when helping establish breastfeeding. Overwhelmingly, midwives and student midwives chose upright positions to help mothers, with 80% either using the Cradle Hold (37.6%), the Cross-Cradle Hold (28.7%) or the Rugby (under the arm) Hold (13.5%). The side lying position was less frequently suggested (13.5%) whilst only 6.8% of respondents cited the LBBF position as the position they most frequently tend to discuss when establishing breastfeeding.

These practices varied across clinical sites (Table 4). For example, a LBBF position was much more likely to be suggested in Unit B than in other hospitals – up to four times more likely than Unit A. However, while overall distribution of breastfeeding positions differed by clinical site, statistical analysis showed only a low level of evidence to suggest an association between breastfeeding position and hospital. (n-237; χ2 = 25.45; p = 0.062).

Table 4 Practice of breastfeeding positions taught compared with clinical site

Those who learned about LBBF through personal experience were almost three times more likely (18.2% vs. 6.8%) to use this position when helping mothers establish breastfeeding. (n = 253; χ2 = 8.03; df 1, p = 0.005).

Almost 5% of respondents were either qualified lactation consultants or midwives/students working towards qualification and may therefore be more likely to have a greater interest in and a wider experience of breastfeeding practices. Of this group 100% were aware of LBBF, with 82% having had specific training about this position which they found helpful for their practice. The remaining 18% stated that they would like to receive this education. Ninety percent of this group also found using this position successful in helping a baby to latch on. All of this group indicated that they felt ‘very’ or ‘somewhat confident’ in using a LBBF position with mothers.

Just over 44% of those who are lactation consultants or were in the process of becoming lactation consultants used it as their most frequent position when helping mothers establish breastfeeding. This is six and a half times higher than the overall respondents’ choice of this position. (n = 253; χ2 = 30.21; df 1, p = 0.001).

Among the remainder of respondents, frequency of using the LBBF position varied. Although most respondents were aware of LBBF, 40 of these respondents (15.8%) said that they never used LBBF when helping mothers to breastfeed. When combined with the 57 respondents who were unaware of LBBF, 38.3% of all respondents (n = 253) had never used this position.

When asked when they would use a LBBF position with mothers, 34% said they would use it as an addition to other positions, 13% said they would only use it when other positions do not seem helpful and 11% stated that they only tend to suggest it immediately after birth with skin-to-skin contact. Just 4% of midwives and student midwives use LBBF as their ‘go-to’ position to encourage a mother’s own skills first.

Education and laid-back breastfeeding

Of those who had heard of LBBF, the majority had learned of it either through their midwifery education (54%) or from lactation consultants (46%). Thirty percent had heard of LBBF from other midwives, 24% from self-directed study such as conferences or reading, 17% from watching mothers and babies, 18% from personal experience of the position and 14% from breastfeeding support groups.

Eighty-five percent of midwives and student midwives had not been formally educated about LBBF. They had not received any training or lectures specifically discussing positional stability for infants and the 20 primitive neonatal reflexes that this position activates. Of the 15% of respondents who had specific education about LBBF, all found it useful for their practice. Of those who were aware of the position, but had no specific training on LBBF, 47% of respondents indicated that that they would like some educational input about it.

Knowledge of laid-back breastfeeding

Respondents were asked to select where LBBF can be done. Laid-back breastfeeding can be done anywhere and does not require special equipment. Most respondents seemed to feel that it is a position best suited to a bed (98%) or a sofa (88%), while a fewer number (65%) chose armchair. Just over a quarter (29%) felt it could be done in public, however only 15% thought it could be done in an upright kitchen chair.

Respondents were then asked to select as many statements as they believed to be true about the environment and benefits of LBBF (Table 5). The statement selected most often as true was about allowing the baby to “head-bob” and self-attach which was selected by 82.5% of respondents. Seventy-five percent believed that using LBBF reduces back, neck and shoulder pain for the midwife. Almost 64% of respondents recognised that this is a position that can be done with the mother and baby fully clothed and 63% that it can reduce breast problems, such as sore nipples, cracked nipples and mastitis. However, just over half understood that this is a position that only requires a mother to be slightly inclined which explains why 85% of midwives and student midwives did not believe it is a position that can be done on an upright kitchen chair. Only 26.3% agreed with the statement that it resulted in greater infant weight gain.

Table 5 Knowledge about LBBFSuccess and confidence using laid-back breastfeeding

When asked how successful using the LBBF position had been with mothers, of those who were aware of it, 5% (n = 10) found it was not at all successful. The remainder who had used the position (74%, n = 143) found it an effective way for baby to latch by either offering encouragement, making a few adjustments, or helping attach baby to the breast in this position. Twenty one percent (n = 41) had never suggested this position.

Despite almost 11% of respondents reporting feeling very confident using this position and over half (54.6%) feeling somewhat confident, the position was still not often suggested when helping mothers establish breastfeeding. Just over 30% of respondents reported they were ‘not very’ or ‘not at all confident’ using LBBF with mothers (Table 6).

Table 6 How confident do you feel using the laid-back breastfeeding position with mothers?Midwifery education specific to lbbf and its effects in practice

Those who had received LBBF training were nine times more likely to cite LBBF as the position they most frequently used compared to those with no training (27% vs 3%), with a significant correlation shown. (n = 181; χ2 = 20.59; df 1, p = 0.008). A large proportion of participants (78.8%) who have not had or are unsure if they have had specific training about LBBF had never used the position with mothers and babies.

For those participants who said that LBBF was their “go-to” position for helping mothers the results showed that they were represented in all roles, including student midwives. However, only 1.8% of respondents who did not have training cited using LBFF as their “go-to” position compared with 22% of those who did. (n = 196; χ2 = 21.21; df 1, p = 0.001).

Of those who had been given specific education about LBBF, 94.3% found using this position successful. However, even for those without this education 70% reported using LBBF successful, which suggests how well the position works when babies are given the chance to latch on in this manner.

However, midwives and student midwives who did receive specific training about LBBF were more confident using this position than those who hadn’t, with 95% either very or somewhat confident, compared to 58% of those who had not received training reporting the same level of confidence (Table 7), with a high degree of association between these two variables. (n = 196; χ2 = 21.12; df 1, p = 0.001).

Table 7 Midwifery education specific to LBBF and effects in practiceBarriers to using laid-back breastfeeding

Fifty-six percent of all respondents (n = 110) who were aware of LBBF submitted an open-ended response about any perceived barriers to using a LBBF position. Seven common themes were identified, mostly citing a “lack of” something (Fig. 1). See Table 8 for respondents’ quotes on this question.

Fig. 1

Main themes related to barriers to using LBBF

Table 8 Quotes from replies to the question: “Do you think there are any barriers that prevent a midwife from using a laid-back breastfeeding position with mothers? If so, please state” 

Lack of time to try a position that may take longer, lack of staff, lack of education/training, lack of knowledge, lack of experience and lack of confidence suggesting this position, and lack of awareness/popularity of it were the main reasons offered as barriers.

Many respondents recognised that reluctance to use LBBF stemmed from historic cultural practices and traditional midwifery teaching to use “hands on” techniques.

LBBF was approached with some trepidation and with concerns about safety issues. Some respondents believed babies may be unstable and could fall or perceived that newborns were too young to feed in this position. Others felt lack of equipment hindered them from using LBBF. However, frequently the barrier suggested by midwives and student midwives to using LBBF were concerns about the mother herself, regarding her anatomy, her emotional state, or her unfamiliarity with the position as a reason they would not suggest LBBF.

Lack of education/knowledge/training

Overwhelmingly, midwives and students mentioned their lack of knowledge about the LBBF position as the biggest reason why they are not comfortable suggesting it. The words “lack of training or education” were mentioned in 28% of the 110 responses to the open-ended question.

Some felt that overall education on breastfeeding for midwives was not enough.

Lack of time/staff shortage

Another common reason for not suggesting LBBF was due to time pressure. Midwives and students frequently mentioned that they didn’t have time to help mothers as they would have liked.

Respondents perceived that the LBBF position takes longer for baby to latch, and it was easier and quicker for the midwife to physically latch the baby to the mother’s breast. Emphasis on pressure to establish the first feed in the labour ward was evident.

Time constraints and under staffing also contributed to a lack of breastfeeding in general for new mothers.

Lack of experience/confidence

In 21% of the total 110 responses, participants suggested that their own lack of experience using this position with mothers led to a lack of confidence in recommending it.

Lack of awareness/popularity

Respondents also recognised that LBBF isn’t often suggested because they just don’t see it used in practice and therefore don’t think to use it.

Cultural/traditional practices

Midwives were very candid in acknowledging that they may not use LBBF with mothers because they were more comfortable to continue using ‘hands on’ positions and found it difficult to revert to a more ‘hands off’ approach.

Other influences

Some participants were influenced by concerns about mothers’ comfort, suggesting that LBBF may be uncomfortable for mothers who may be in pain from an instrumental birth or Caesarean section. However, some midwives felt LBBF is the best position to use for mothers post Caesarean section.

Maternal issues

Twenty-eight percent of the open-ended responses cited specific issues with the mother or her baby as a reason for not using a LBBF position. For the mother, issues such as her anatomy (large breasts, flat/inverted nipples, raised BMI), her anxiety, her lack of understanding or her unwillingness to try something new were mentioned. For the baby it was difficulties with latch and/or a sleepy baby.

Equipment/environment issues

Some midwives felt that the hospital environment itself or poor equipment made it difficult to suggest LBBF to mothers. These included lack of pillows, ward layout and lack of bedspace. Some midwives felt lack of available chairs at the beside was a barrier while others thought that they couldn’t suggest LBBF if a mother was seated in a chair at the bedside.

Other issues

A number of respondents felt it was a position better suited to older babies and not easy to get newborns to feed in this position. Some respondents expressed concerns about the safety of using this position, regarding the stability of the baby, especially when mothers were tired.

Students found it challenging to apply their knowledge of using a LBBF position to the clinical area when it was not already being practiced there.