Maternals´ experiences and perceptions in communication relationship with health professionals during breastfeeding counseling. A Qualitative study.

Maternals´ experiences and perceptions in communication relationship with health professionals during breastfeeding counseling. 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A Qualitative study. Marina Leal-Clavel, Inés González-Sánchez, Esther Mancheño-Maciá, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8157994/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background . The primary objective of this study is to explore the key aspects of the therapeutic relationship between professionals and the mother-baby dyad from the mother's perspective. The World Health Organization advocates participatory research to enhance the efficacy of breastfeeding promotion interventions. A comprehensive understanding of the factors deemed significant by mothers is instrumental in the effective planning of communication skills training for the professionals entrusted with their care. Methods . The present study employed qualitative content analysis, drawing upon Glaser and Strauss' grounded theory, and encompassed in-depth interviews and participant observation. The study comprised mothers of infants born in the last five years who had expressed a desire to offer exclusive breastfeeding for a period of six months. Participation was voluntary, anonymous and without language barriers. The analysis was conducted utilizing the software program Atlas.ti v25. Results : Theme 1: Maternal feelings and emotions during birth and breastfeeding. Category 1: Maternal emotional moments: positive feelings such as encouragement, confidence and gratitude, and negative feelings such as fear, guilt, loneliness and misunderstanding. Category 2: The therapeutic relationship: mothers value empathy, respect, active listening and personalised treatment. Category 3: Healthcare environment: barriers such as mechanised care and lack of staff are perceived in the public system, while limited access and high cost are perceived in the private system. Category 4: Support network: The importance of support groups for mothers and their partners in terms of decision-making and emotional support is emphasised. Conclusions : Mothers' perception of the knowledge and skills that professionals have acquired and demonstrated in the management of breastfeeding influences their confidence. The most important factors are empathy, accessibility, respect, closeness, trust and a personalised approach prior to counselling. They value accessible and reliable spaces where they can discuss their physical and emotional health. Breast Feeding consultation Communication skills Counseling breastfeeding Mothers Professional-Patient Relations Qualitative Research BACKGROUND The optimal form of feeding for infant growth and development is exclusive breastfeeding (EBF) for six months of life and, together with other complementary foods, for a period of up to two years or more. The evidence and recommendations of international scientific organizations support this approach, as they do for many other aspects of infant feeding. [ 1 – 4 ]. It has been demonstrated that this behavior functions as a form of protection for the mother against diseases [ 5 ], improving their mental health [ 6 ]; and human milk is considered by the Centers for Disease Control and Prevention (CDC) to be ‘the clinical gold standard for infant feeding and nutrition’, reducing a baby's risk of disease, sudden infant death and obesity [ 5 , 7 ]. Furthermore, it has been demonstrated that this practice has a beneficial effect on the intellectual level of infants [ 8 ]. Breastfeeding is regarded as a matter of public health significance and is recognized in the United Nations Millennium Development Goals [ 9 ]. In Spain, in 2018, EBF rates were 66.4% at 15 days and 35.2% at 6 months. More than 90% of women chose BF at birth, highlighting the problem of early BF abandonment in Western countries [ 10 ]. Professional interventions have a strong positive impact on both initiation rates and long-term continuity and exclusivity, if they are delivered optimally [ 3 , 11 – 14 ]. It is recommended that interventions be developed on an individualized basis for each mother-baby pair to improve outcomes. These interventions should take the form of early counselling during observation of infant feeding [ 14 ], and adequate training of professionals and community actors [ 11 ]. It is imperative to provide both formal and informal support to mothers, facilitating their success in breastfeeding [ 4 , 15 – 17 ]. The World Health Organization (WHO) [ 18 , 19 ], in its training course on breastfeeding counselling for professionals, defines breastfeeding counselling or 'counselling', as 'the action of helping to decide what is best for you, not just advising or telling you what to do; it is listening to the mother, trying to understand how she feels and helping her to develop self-confidence so that she can take control of the situation'. In this training, the WHO advises that all actors who come into contact with the mother should be trained in maternal counselling, which includes skills in breastfeeding management and communication skills for an effective therapeutic relationship. It has been asserted by certain authors that this training proposal is highly focused on the skills of professionals [ 20 , 21 ] and not so much on the non-verbal signals of the mother, highlighting also that counselling is an aspect that is little known and valued by professionals, even though this area is little researched [ 22 – 24 ]. According to the limited evidence available, the communication skills of professionals during the counselling process are poor [ 20 , 21 ], It is important that mothers have support for their self-efficacy and empowerment through professional interventions that are adapted to their individual needs [ 16 , 25 – 28 ]. The main objective of this study is to explore the key aspects of the therapeutic relationship between professionals and the mother-baby dyad during BF counselling from a maternal perspective, as opposed to the communication skills framework recommended by the WHO during training in breastfeeding counselling [ 18 , 29 ].The WHO recommends [ 3 ] user consultation to improve effective interventions for breastfeeding promotion. Knowing what mothers value as important through participatory research designs will help us to better plan future training for the professionals who will care for them. METHODS Study design The research was conducted under a qualitative descriptive design based on Glaser and Strauss' Grounded Theory [ 30 ]. In addition, the deductive research was guided by the Ecosystemic Model of Urie Bronfenbrenner's Theory due to its phenomenological approach [ 31 , 32 ]. This model is applicable to the complex functioning of the mother-baby dyad and the other determinants that condition the different experiences, environments and social conditions where perinatal care is provided. As a method of interaction with the participants, in-depth interviews and observation by the researcher were used. The Consolidated Criteria for reporting Qualitative Research guidelines (COREQ) were utilized to evaluate the quality of the qualitative research in terms of design, interviewing, analysis of results, and other pertinent aspects [ 33 ]. Participant selection and sampling Descriptive exploratory qualitative studies are defined as those that provide information about an experience from the perspective of the people who live it, with the objective of increasing understanding [ 34 ]. The qualitative methodology allows the informants to volunteer to participate, as they are experts in the subject matter [ 35 ]. To recruit the study population, the local breastfeeding support group was contacted and informed of the objectives and methodology of the project and approval was requested to inform its members about participation and to carry out information dissemination through their social networks. The snowball sampling procedure was used. This non-probability sampling by convenience made it possible to establish a pyramidal effect in the diffusion of the participation information. The inclusion criteria were mothers of infants born within the last five years who wish to offer EBF for the first six months and maintain it with complementary feeding. Exclusion criteria were mothers who have a language barrier. The indicators for assessing infant and young child feeding practices recommended by the WHO were used to classify the type of feeding according to the age of the infant [ 36 ]. Mothers who agreed to participate in the study established communication with the research staff by e-mail. A phone call was then made to arrange the interview on the day and at the location agreed upon by the mother and the interviewer, in a quiet, reliable, and easily accessible location for the mother. The study sample was closed when data saturation was reached, and the collection of new information did not provide new insights into the research questions. Data collection Data were collected through semi-structured individual interviews conducted by research staff with extensive training and experience in breastfeeding counselling and support. During the interview, mothers were invited to talk freely about key aspects of the study so that they could openly express their feelings, emotions, and experiences without being interfered with by the interviewer. The semi-structured interview, the content included a series of four open-ended questions based on the objectives of the study and the existing bibliography. In addition to the interview, sociodemographic and other relevant data on pregnancy, mode of delivery and breastfeeding were collected using an ad hoc data collection sheet. All interviews were recorded and stored in audio format after written consent was obtained from the participating mothers. They were then transcribed literally and identified with an alpha-numeric code to guarantee anonymity. Mothers were identified for the study using the pseudonym "M" followed by the order number of entry into the study, with “M1” being the first mother interviewed and “M16” being the sixteenth. The interviews were conducted between July 2023 and December 2024 and lasted on average 28.5 minutes (ranging from 43 to 17 minutes). Data analysis All interviews were recorded and subsequently transcribed verbatim and then analyzed using the method of thematic analysis proposed by Braun and Clark [ 35 ]. This method of analysis includes different phases of information processing, including: 1) The search for structures and meanings, through transcription, reading and annotation of general ideas; 2) Coding the content of the sentences, grouping the codes to generate categories and subcategories; 3) Creation, revision and definition of the themes according to the convergences of meaning, context or temporal circumstance of the previous categories; and 4) Preparation of the final results report. To ensure validity and reliability in the interpretation of the results, a triangulation process was employed by the study's authors, utilizing a comprehensive data set. The organization and interpretation of qualitative data was carried out using the ATLAS.ti- 25 software. Ethical aspects The study was authorized by the Bioethics Committee of the Cardenal Herrera CEU University (reference code: CEEI22/359). Participation in the study was voluntary, anonymous and confidential, with no language barrier hindering communication. Participants were provided with the study information sheet and informed of consent for their approval to participate and be recorded during the interview. This consent could be revoked at any time. The study complied with the ethical principles for medical research involving human subjects according to the 75th Declaration of Helsinki of the World Medical Association [ 37 ]. RESULTS Participants characteristics After applying the selection criteria described in the methodology section, a total of 16 mothers agreed to participate in this study. The age range of the participating mothers was between 28 and 44 years (mean 35.7 years). Of the 16 women, 7 (43.7%) had a university education and the rest (56.25%) had intermediate education. Only one mother was unemployed at the time of the interview and two of them lived with their children without a partner. Nine of the mothers had only one child and the rest had two. The age of the last child ranged from 1 month to 3 years. The data pertaining to the subjects' birth and breastfeeding histories revealed that 6 of the 16 women (37.5%) underwent a caesarean delivery. Furthermore, 7 of these women (43.8%) indicated that they initiated breastfeeding within the first minute of life. In addition, 5 of the subjects (31.2%) were able to breastfeed within one hour of birth, while 4 of them (25%) required several hours to do so. Half of the women maintained exclusive breastfeeding during the first six months of life, all the mothers who reported their intention to breastfeed before delivery. The duration of breastfeeding was found to vary considerably after the first six months of the infant's life, with five cases of weaning occurring at the time of the interview. Of these five cases, three were attributed to the scheduling of the second pregnancy, while the remaining two were attributed to a lack of support and pain. Main results The following findings emerged from the process of analyzing the transcripts of the mothers' interviews, as described in the Methods section. The experience and perceptions of the mothers who were interviewed in this study were classified as 1 theme (maternal experiences in the birth and breastfeeding process), 4 categories and 7 subcategories. These categories and subcategories are described below in this section of results. The grouping, ordering and relationship of the main ideas was carried out following the theoretical bases previously exposed on the evidence related to the therapeutic relationship and communication [ 38 , 39 ] and the ecological model [ 31 , 32 ]. Maternal experiences in the birth and breastfeeding process (Theme) The texts describe the experiences of mothers during the process of childbirth and breastfeeding care and how they felt about everything that happened to them. They also mention what they value most in the care they receive and what they consider important to make the therapeutic relationship with the professional as satisfactory as possible in this process. Mothers have reported positive experiences and highlighted empathy and effective communication as crucial factors for a positive experience. The support provided by midwives and mothers' groups was received favorably. Concurrently, there were numerous negative experiences, including inadequate diagnosis, discourteous treatment, absence of empathy, and deficient information provision. Furthermore, the findings revealed that mothers held a perception of health professionals as lacking in knowledge regarding breastfeeding. This perceived deficiency in expertise engendered a state of distrust and skepticism among the mothers towards the support they sought. This situation gave rise to a range of emotions including frustration, anxiety and a sense of helplessness among the mothers. It was generally observed that women placed a strong emphasis on the necessity of care during breastfeeding that was personalized, respectful and well-informed (Tables 1 , 2 and 3 ). Mother's feelings and emotions (category 1) This category comprises the feelings and emotions expressed by mothers during interviews. These may be triggered by healthcare professionals at specific moments of care, or by memories and circumstances of past events related to their previous experiences. Furthermore, the discourse of the mothers is characterized by the articulation of their personal sentiments and emotional responses, which are inextricably linked to their individual expectations and the unique circumstances that they encounter during the therapeutic relationship. The subjects have been classified as positive or negative, based on the literal description provided during the interview, to avoid any potential interpretations by the researchers (Table 1 ). Seven condensing units were identified as positive, highlighting the importance of feeling comfortable and secure in the breastfeeding process, as well as empathy and individualized attention from health professionals while providing emotional and educational support during the therapeutic relationship. The importance of feeling accompanied and empowered is also emphasized, as well as the positive valuing of effective communication and trust generated during this experience. Respectful interaction and closeness of care are perceived as key factors for the emotional and physical well-being of mothers during breastfeeding. The support group also generates positive feelings in the maternal account. During the narratives there are situations resulting from mothers' interaction with health professionals. In these stories, mothers recount times when professional advice is absent, insufficient or ineffective, resulting in feelings of mistrust, sadness or disappointment in the professional support system. They have felt that breastfeeding was in danger because of pain or lack of information, and they have felt very lonely, helpless, anxious and afraid. No negative experiences are mentioned when care is provided in the support group. Mothers’ express feelings of low self-confidence, guilt or feeling that they are bad mothers when the professional does not consider their lack of skills, insecurity in maneuvers or knowledge. They feel that they are judged and that the staff makes it difficult for them to assert their maternal role, which lowers their self-esteem. Table 1 Category that describes feelings and emotions (category 1) Category Subcategory Condensing units. Quotations Feelings and emotions MEM positive Encouragement. M7 : ‘My paediatrician tells me the truth; I changed paediatricians between my first (son) and second (son). She reassures me and encourages me, she encourages me to keep going, even with the older one. My current paediatrician encourages me, the previous one didn't, she neither encouraged nor discouraged me’. Security, peace of mind. M9 : ‘I felt safe, it gave me security, it gave me peace of mind, even though it might not work out the theory that we had. But I had that security and that peace of mind that I knew that if I needed something, he was going to be there and he was going to help me’. Comfort, closeness . M11 : ‘They are very good feelings because I feel very safe and I feel especially comfortable when I have sessions with her, because she gets involved, helps you, comments, does everything with affection and in the end also makes you feel accompanied. She focuses a lot on you as a person’. Empowerment, confidence. M4 : ‘My paediatric nurse gave me that confidence. I felt like I was always doing everything right; she never said anything that made me worry about my son's health. All that gives you strength and confidence, reassures you, and encourages you to keep going’. MEM negative Anxiety and worry, confusion, misunderstanding . M8 : ‘It's just that my nipples aren't flat, they're flatter than normal. So, the girl gave me a nipple shield, and it worked fine. Two hours later we had the same problem again. I felt like they were giving me solutions to my distress and concerns, but I felt that something wasn't right’. Anxiety and stress, lack of support, helplessness. M 11 : ‘Well, the truth is that it's pretty bad, I mean, on top of that, no one, I mean, no one offers you help, the help they offer you isn't what you need, and on top of that, you've just given birth, literally two hours ago, and you ask yourself, 'Well, what do I do now? It's a feeling of helplessness!’. Pain, disappointment, frustration. M4 : ‘Honestly, I tell you, the predominant emotion was disappointment. With the second one, about which I already had much more information, I felt a little disappointed, because I realised that much of the advice, they gave you or the way they told you things, contradicted each other among the healthcare staff’. Loneliness, abandonment, resignation . M7 : ‘With the first one, it was absolute loneliness, and with the second one, I suppose experience counts for something, so the loneliness was less, but it was almost me, with my convictions, who was so sure that I would have gone to India and come back if I had had any problems’. Judged. M13 : ‘It made me feel like a bad mother. I was trying to bottle-feed her. And then she [the nurse] came in and said, “Leave it to me, you don't know how to do it”. M6 : ‘Yes, I can tell you that I left (the health centre) crying, I felt like an idiot, they made me feel that way, they made me feel like I had no idea what I was doing, and maybe it was true, I can tell you that, but I go there precisely to be taught and helped’. Discomfort, anger, unpleasant moment not asking permission to touch . M2 : ‘And then (the nurse) grabbed my breast, grabbed my breast, grabbed the baby's head and forced him to do it, a bit like saying, “That's where it has to be ” . I didn't like her attitude. She should have said, “I'll explain it to you“, and asked first, “Can I hold the baby? Can I put him on my chest? ” ’. Fear, sadness and depression, guilt, vulnerability . M6 : ‘Yes, I can tell you that I left (the health centre) crying, I felt like an idiot, they made me feel that way, they made me feel like I had no idea what I was doing, and maybe it was true, I can tell you that, but I go there precisely to be taught and helped. losing my milk supply. So, I tried everything I could, but no, no, he wouldn't latch on or he would only latch on to one breast, and the breast he latched on to hurt’. MEM: Mother´s emotional moments Therapeutic relationship (category 2) Participants shared their experiences during the therapeutic relationship with health professionals (mainly midwives and pediatricians), highlighting the importance of feeling listened to, supported and validated in their emotions (Table 2 ). Particular’ problems were reported in the study, such as difficulty in initiating breastfeeding, difficulties in latching on and experiences with pain when breastfeeding. A significant proportion of maternal comments focused on a perceived lack of attention to the needs and concerns inherent in the maternal role, which often led to feelings of anxiety and loneliness among mothers. Some mothers found comfort in support groups and professionals who demonstrated a genuine interest in their emotional and physical well-being. In contrast, other mothers reported feeling neglected or with little support from health staff. The recurrent theme of knowledge and training of professionals was also noted, with some participants citing the lack of updating on breastfeeding issues by pediatricians and nurses as a cause of doubt and frustration. The utilization of nipple shields to alleviate discomfort is prevalent, suggesting a deficiency in professional expertise. Effective communication and empathy were key factors in generating positive experiences. In contrast, the absence of such skills led to feelings of helplessness and mistrust. Maternal reflections show that sympathetic care and a willingness to listen with personalized care are fundamental to their emotional health and their perception of efficacy and supportive experience, as well as to ensure a successful and satisfying breastfeeding process. Women´s support network (category 3) Mothers feel more supported and understood in support groups with other mothers than with health professionals. They share their experiences and feel supported in their breastfeeding decisions. Interaction with other parents through WhatsApp groups and breastfeeding workshops gives them comfort and help. Sometimes they feel that health professionals do not have all the tools they need to help, so they turn to external specialists. Empathy and support from the community of mothers are essential to feel empowered and confident in their decisions. Lack of information and visible references in the social environment can create discomfort and the need to unlearn long-held beliefs about breastfeeding (Table 2 ). In the accounts of some women, reference is made to partners and families. The term 'breastfeeding support' refers to the assistance provided to mothers in upholding and sustaining their decision to breastfeed, in making collaborative decisions regarding matters pertaining to pregnancy and childbirth, and in engaging in collaborative efforts, both in the execution of procedures and in challenging circumstances, with the objective of promoting and maintaining breastfeeding. Table 2 Categories that describe therapeutic relationship and women´s support network (category 2 and category 3) Category Subcategory Condensing units. Quotations Therapeutic relationship Keys to care according to the mother Listening, support, trust, validation . M14 : ‘I think all communication skills are important, really. But feeling listened to, I think that has also helped me. Not minimising my problems, not feeling like they're silly. Being listened to, having time dedicated to you, is important. Then, the feeling of support and training, and then trust. Feeling supported and listened to, and I can really relate to that. Because in the end, I think that just listening to me is a way of supporting me’. Personal attention, understanding, availability . M10 : ‘After giving birth, she looked after me. She was supposed to see me once, but she saw me three times. I wrote to her through the app and she replied to the same day. They really helped me, they had a different way of communicating, more affectionate, more intimate. They give you the feeling that they are less in a hurry, even though they may be just as busy, but they make you feel that they are less rushed. They see you; they help you get settled, they make suggestions’. Clear communication. M15 : ‘No, the second time it was very clear to me. No one told me anything clearly, neither the midwife nor the hospital. .as it was an emergency caesarean, no one told me anything, they just said: ‘Put it on!’ And I said, “But how? I can't move, my whole-body hurts”. I cried. They said, “Don't cry, just put him down!’. Kindness and gentleness, respect, empathy. M13 : ‘The girl I really liked was the neonatal nurse; she was so sweet. She said, “Look, can you let me? If you want, if you can lift your arm a little, I'll put the pillow here”, everything with a lot of respect, a lot, nothing abrupt. The other girl picked him up, well, of course, you pick up babies every day and you pick them up with one hand, but when I pick up my son, I think he's going to break, but this neonatal nurse was so sweet. She picked him up, asked my permission, “Look, move him a little bit here, me a little bit there”. I don't know, she was so peaceful. The other one, she wasn't aggressive, but she gave off an aggressive vibe’. Ethical treatment, learning. M6 : ‘Yes, I'm telling you, I left there crying. I felt like an idiot... like I had no idea what I was doing, and maybe that was true, I'll tell you that too, but I went there to be taught and to be helped’. Women´s support network Peer support Parents Comfort, listening, a warm space . M7 : ‘I arrived at the support group for mothers and found it to be a relaxed space. Although the room was untidy, it felt like a warm environment. I felt listened to and understood, because until then I had never felt understood, and I felt that my emotions were valid. So here I am, it was what I needed’. Sharing experiences, understanding and support. M10 : ‘The association, the WhatsApp group of mothers, the mothers who wrote to me privately to tell me about their experiences, how they had managed to help and support me, and the mothers in the group we have formed in the breastfeeding workshop at the health centre, we have created a wonderful tribe. They have helped me simply by being in a place where you can let off steam and talk about your experience’. Seeking support . M10 : ‘For me, being in this group and being able to read about all the problems people have and the solutions you give them gives me a lot of peace of mind, also because I see that this is something that is not seen in the world. M14 : ‘She came to the mothers' group looking for support, comfort and sharing’. Mutual support, collaboration, decision-making. M4 : ‘I feel very supported by the staff, but what I really need is the support of my partner and my family. Whether the paediatric nurse supports me or not, I really don't care, because I'm going to do what I want with breastfeeding. What I do need is the support of my loved ones’. Healthcare environment (category 4) In the maternal comments, there are references to the conditions of care depending on whether it is in the public sector (hospitals and primary health centers of the public health network) or in the private sector (private clinics specialized in parenting care). Both contexts are part of the network of maternal care in the health sector and are influenced by the human and material resources available to women (Table 3 ). Mothers experience frustrations stemming from the lack of personalized care and limited resources in public administration. A growing demand for greater availability, training and resources in the health system has been observed. Unfulfilled appointment requests and a perceived lack of patience to deal with them have also been identified. In addition, it has been identified that limited time in consultations can make care mechanized and depersonalized. Mothers also expressed gratitude for the availability and attention of some midwives. They commented on the existence of a certain conflict of interest between the professionals working in both sectors. Mothers expressed dissatisfaction with the care received in public environments compared to private health care, where they found the diagnosis and treatment of their children to be quicker and of higher quality. The importance of effective communication and the provision of personalized care, particularly in the context of breastfeeding and mental health issues, is emphasized. The absence of updating and the prioritization of concrete solutions by certain health professionals has engendered mistrust and discontent among mothers, who hold the support and empathy provided by private midwives and specialists in high regard. Some informants detect a conflict of interest in the referral of public sector professionals to private clinics, involving an expense that not all families can afford after the arrival of a baby. Table 3 Categories that describe Healthcare environment (category 4) Category Subcategory Condensing units. Quotations. Healthcare environment Public sanitary environment Mechanised care, fast care, work stress. M4 : (talking about the consultation at the health centre) “You know that if you go when you're in a hurry and they're rushing and don't say anything to you, even if they don't say it, you somehow know that there's not much time for the consultation. Besides, you know there are always people waiting. One person leaves, another comes in. ... No one asks you any questions. You get the feeling that it's more like, ‘Come on, let's weigh the baby, measure him, give him his vaccinations, and how is the baby feeding?’, and that's it”. Perception excessive workload. M 7: (talking about the midwife in the postnatal ward) “... the thing is, she could only help you for five minutes. Because she had to see many more patients throughout her shift. So, of course. I remember it like this: ‘Let's talk, bye, bye, bye.’ I'm not asking for a one-hour consultation, but I am asking for at least 15 or 20 minutes”. Discontinuity of care, lack of availability, lack of training, inexperience. M 11: “... But in the ward he didn't want to breastfeed, and it hurt a lot when he did. So, I called the nurses, but as it was Sunday night, all the staff were paediatricians... So, until the next day, when the midwife didn't come, we tried to get her to latch on, but she was in a lot of pain all night, and when her shift ended, she left and didn't want to try again, so we were left in the same situation”. Conflict of interest, difficulty accessing care . M6: “In a public place... maybe she could have helped me more, but it's not her job as a midwife, but as a physiotherapist... Because I know she's a physiotherapist, and when I went there with the problem and everything, maybe she could have looked at it and... Sure, sure, but it's not her job” Knowing how to refer, lack of staff . M2: “Let's see, first of all. That the professional, perhaps it's not difficult, but that they are trained in everything that currently exists, and if they don't know, that they tell me no, that they are not trained, but that there is a specialised centre that can help me. In other words, honesty in admitting that they don't know, and that's the option. And then, above all. Let's see, what I've found lacking in the National Health Service is the lack of resources, that is, if a physiotherapist doesn't do it, you have to pay for it yourself. So it's like, yes, thank God I have money, we work and I can afford it, but...”. Protocols : M 10: "They rely heavily on protocols... but in my view, that's not incompatible with personalising care. So, when I ask them for certain care based on scientific evidence... well, they're not used to that. They're used to following a protocol, and when you ask them for something that's not in their protocol, they feel a bit lost. That's my feeling. And then it bothers them when you challenge them, even politely, because I think they're more used to telling patients what to do and the patient obeying." Private sanitary environment Problems with tongue-tie detection, exclusivity of private care, difficulty accessing care. M4: “The second time I stopped breastfeeding, tongue-tie problems, etc. Well, gas, pain, tongue-tie that no one in the public sector knew how to detect. Well, I had to resort to the private sector thanks to my knowledge. Otherwise, it would probably have been a failed breastfeeding experience, because, well, we all know what it means to have ankyloglossia”. Provision of private help, paediatric specialities. M 16: “Of course, I was in incredible pain. And then we also went to an external breastfeeding consultant (from the private sector), because we had another crisis two days later, and we didn't understand anything, we didn't know how it had happened or why it was happening, and then, ten days later, I had my first blockage...And as I had already read a lot, someone had asked about it in the (mothers' support) group and they explained it to her, and she (the private midwife) gave me some links to look up on the Internet. High cost. M 9: “Not at X (name of private physiotherapy clinic), they did give him tongue strengthening sessions, which did help him to latch on properly, but after the third session I felt that it was pointless, that we were just sitting there, paying a fortune because it was so expensive, and the child wasn't doing anything”. Private mental health. M 10: “In the end, because I asked the midwife at the health centre, they referred me to mental health, but they took so long to call me that I ended up going private, also to my psychologist”. DISCUSSION The analysis of the results shows that existing literature presents important similarities in the phenomenon studied. The mothers in our study emphasize the importance of personalized treatment and the need to improve professionals' training in breastfeeding and counselling skills. Research in the field of maternal experiences in childbirth and breastfeeding shows, as in our results, that mothers value qualified breastfeeding support, and for this support to be effective, it is important to focus on the individual needs of each mother and improve the training of support staff [ 24 , 28 , 29 , 40 – 45 ]. Yang Y et al.[ 24 ], in their recent review on the subject, call for the optimization of peer support services and the strengthening of their role in promoting breastfeeding. In our study, mothers describe these spaces as safe and supportive places for breastfeeding, where there are no communication or relationship problems. In contrast, there are repeated instances of conflict and communication problems between professionals and the mothers interviewed. According to the meta-analysis by Chesnel MJ, Healy M, McNeill J [ 29 ] which analyzed the opinions of 368 participants in 21 articles, it is clear that the potential of each experience to facilitate or inhibit breastfeeding is a complex and changing process that depends on the context, highlighting the importance of the mother's perception of the personalization of the process as a key element in ensuring successful breastfeeding. Our sample of accounts emphasizes the need for personalization of the process and the need to feel that care is tailored to the special needs of each mother-baby pair and their contexts. Research examining the impact of communication skills from maternal and professional perspectives is limited [ 23 , 24 , 46 ]. According to Burns [ 47 ], mothers' perceptions of their caregivers' level of knowledge and training can influence their trust in the caregiver Mothers worry about whether the advice given will solve the problem or whether it is appropriate at the time it is given. This is a source of mistrust that also appears in our study, and which ultimately determines the relationship of trust with that professional, even leading to the mother leaving the care system to seek alternatives such as private sector lactation specialists or informal support groups. According to Patel S [ 26 ] this situation could be optimized by referring mothers to accredited lactation consultants, such as IBCLCs (International Board-Certified Lactation Consultants). This procedure would lead to more favorable results in the resolution of breastfeeding problems, since, according to the available evidence, the level of knowledge of accredited consultants exceeds that of standard practitioners [ 48 ]. CONCLUSIONS After a thorough examination of the results of the analysis of the maternal narrative, the following conclusions can be drawn. 1. The mother's perception of the level of knowledge and skills acquired and demonstrated by the professional in the management of breastfeeding can influence the mother's relationship of trust with the professional and her concept of herself as a mother. Mistrust generates feelings of guilt, a breakdown in trust and, in some cases, a search for alternative care in the private sector. 2. The most important aspects of communication are empathy, accessibility, a relationship of respect, closeness and mutual trust before counselling, and friendly treatment. 3. It is important for the mothers in our research to feel that they are receiving personalized treatment, with opportunities during consultations to be asked, beyond the breastfeeding situation, about their physical and emotional state and other circumstances that determine their motherhood and parenting process. Declarations Acknowledgements: We would like to thank the group of mothers who gave their time and trust to carry out this study. Ethics approval and consent to participate and publication: The study was authorized by the Bioethics Committee of the Cardenal Herrera CEU University (reference code: CEEI22/359). Participation in the study was voluntary, anonymous and confidential, with no language barrier hindering communication. Participants were provided with the study information sheet and informed of consent for their approval to participate and be recorded during the interview. This consent includes the publication of the information. Availability of data and materials. The anonymised text material collected during the interviews with the mothers is archived and available for consultation. Funding: This study was conducted without financial support from public, private, or non-profit institutions. Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests. Author contributions: L.M. participated in the design of the first draft of the manuscript, carried out the intervention, data analysis and collaborated in the editing of the final manuscript. G.I. co-wrote the first draft of the manuscript, directed the data analysis, and collaborated in the implementation of the intervention. M.E. collaborated in the data analysis. E.V. participated in the study design, directed the implementation of the intervention and data analysis, and edited the manuscript. Affiliations: Marina Leal-Clavel 1 * , Inés González-Sánchez 2 , Esther Mancheño-Maciá 3 , Vanesa Escudero-Ortiz 3 . Department of Nursing and Physiotherapy, School of Health Sciences, Universidad Cardenal Herrera-CEU, CEU Universities, 03203 Elche, Spain Nursing Subdivision. Hospital General Universitario Dr. Balmis-Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL Grup 23. Innovation in nursing care), Alicante, Spain. Department of Biomedical Sciences, School of Health Sciences, Universidad Cardenal Herrera-CEU, CEU Universities, 03203 Elche, Spain. References Horta BL, Loret de Mola C, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and meta-analysis. Acta Paediatr. 2015;104:30–37. Medline: 26192560 doi: 10.1111/apa.13133 Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, et al. 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A meta-ethnographic study of health care staff perceptions of the WHO/UNICEF baby friendly health initiative. Women Birth. 2014;27(4):242–249. Medline: 24957926. doi: 10.1016/j.wombi.2014.05.005. Sriraman NK, Kellams A. Breastfeeding: What are the barriers? why women struggle to achieve their goals. J Womens Health. 2016;25(7):714–722. Medline: 27111125. doi: 10.1089/jwh.2014.5059. Yang Y, Liu H, Cui X, Meng J. Mothers' experiences and perceptions of breastfeeding peer support: A qualitative systematic review. Int Breastfeed J. 2024;19(1):7. Medline: 38243287. doi: 10.1186/s13006-024-00614-3. Demirtas B. Strategies to support breastfeeding: A review. Int Nurs Rev. 2012;59(4):474–481 Medline: 23134130. doi: 10.1111/j.1466-7657.2012.01017.x. Patel S, Patel S. The effectiveness of lactation consultants and lactation counselors on breastfeeding outcomes. J Hum Lact. 2016;32(3):530–541. Medline: 26644419. doi: 10.1177/0890334415618668. Zwicky A, Thaqi Q, Hediger H, Naef R. 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Indicators for assessing infant and young child feeding practices: definitions and measurement methods. Geneva: 2021. Available from: https://www.who.int/publications/i/item/9789240018389 Accessed: 7 Dec 2024. WMA - The World Medical Association-WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants. 2024. Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki/ Accessed: 7 Dec 2024. Moreno-Poyato AR, Delgado-Hito P, Suárez-Pérez R, Leyva-Moral JM, Aceña-Domínguez R, Carreras-Salvador R, Roldán-Merino JF, Lluch-Canut T, Montesó-Curto P. Implementation of evidence on the nurse-patient relationship in psychiatric wards through a mixed method design: Study protocol. BMC Nurs. 2017;16(1). Medline: 28096737. doi: 10.1186/s12912-016-0197-8. Florez-Escobar IC, Castellanos-Fuentes YE, Quemba-Mesa MP, Vargas Rodriguez LY. Comunicación terapéutica y terapia narrativa: Aplicaciones en el cuidado de enfermería. Rev cienc cuidad. 2023;20(3). doi.10.22463/17949831.3854. Balogun OO, O'Sullivan EJ, McFadden A, Ota E, Gavine A, Garner CD, Renfrew MJ, MacGillivray S. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev. 2016 ;11(11). Medline: 27827515. doi: 10.1002/14651858.CD001688.pub3. Berwick M, Louis-Jacques AF. Prenatal counseling and preparation for breastfeeding. Obstet Gynecol Clin North Am. 2023;50(3):549–565. Medline: 37500216. doi: 10.1016/j.ogc.2023.03.007. Murphy R, Foley C, Verling AM, O'Carroll T, Flynn R, Rohde D. Women's experiences of initiating feeding shortly after birth in Ireland: A secondary analysis of quantitative and qualitative data from the national maternity experience survey. Midwifery. 2022;107. Medline: 35121172. doi: 10.1016/j.midw.2022.103263. Gavine A, Shinwell SC, Buchanan P, Farre A, Wade A, Lynn F, Marshall J, Cumming SE, Dare S, McFadden A. Support for healthy breastfeeding mothers with healthy term babies. 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Understanding the challenges related to breastfeeding education and barriers to curricular change: A systems perspective for transforming health professions education. Can Med Educ J. 2022;13(3):91–104. Medline: 35875442; doi: 10.36834/cmej.73178. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8157994","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":552151018,"identity":"a36c204c-9c55-438c-a89a-a0f2bb789c7d","order_by":0,"name":"Marina Leal-Clavel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIie2OsQrCMBRFnxTi8iBri9I/ECKFKCj6K4FCXfyADg6Fgi4F135OJaBLwTVjQehccOmkpji4mbo55MCFN7zDvQAWyz8y1KkAxhSA9FQcHQGAXvKzwoq+yiR1To2AJQYqrKs2lkBp8V3hkoSugAi5imbTrJTg5cKkINOK1MqWjAZ7CUwZhnFJ762AJwZ5pzwkrK/GYUh0S6G7OiXRLWAcRvhcsBDdsuZedt6gq0zKJb2pJl759BDWbrtb+PRoGPaGfU7s82+xWCwWAy+CWDrPuNtmjAAAAABJRU5ErkJggg==","orcid":"","institution":"Universidad Cardenal Herrera-CEU, CEU Universities","correspondingAuthor":true,"prefix":"","firstName":"Marina","middleName":"","lastName":"Leal-Clavel","suffix":""},{"id":552151019,"identity":"8d98920c-2946-469b-9d26-c9ff22bfb557","order_by":1,"name":"Inés González-Sánchez","email":"","orcid":"","institution":"Nursing Subdivision. 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A Qualitative study.","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe optimal form of feeding for infant growth and development is exclusive breastfeeding (EBF) for six months of life and, together with other complementary foods, for a period of up to two years or more. The evidence and recommendations of international scientific organizations support this approach, as they do for many other aspects of infant feeding. [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It has been demonstrated that this behavior functions as a form of protection for the mother against diseases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], improving their mental health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; and human milk is considered by the Centers for Disease Control and Prevention (CDC) to be \u0026lsquo;the clinical gold standard for infant feeding and nutrition\u0026rsquo;, reducing a baby's risk of disease, sudden infant death and obesity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, it has been demonstrated that this practice has a beneficial effect on the intellectual level of infants [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Breastfeeding is regarded as a matter of public health significance and is recognized in the United Nations Millennium Development Goals [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In Spain, in 2018, EBF rates were 66.4% at 15 days and 35.2% at 6 months. More than 90% of women chose BF at birth, highlighting the problem of early BF abandonment in Western countries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eProfessional interventions have a strong positive impact on both initiation rates and long-term continuity and exclusivity, if they are delivered optimally [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It is recommended that interventions be developed on an individualized basis for each mother-baby pair to improve outcomes. These interventions should take the form of early counselling during observation of infant feeding [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and adequate training of professionals and community actors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is imperative to provide both formal and informal support to mothers, facilitating their success in breastfeeding [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], in its training course on breastfeeding counselling for professionals, defines breastfeeding counselling or 'counselling', as 'the action of helping to decide what is best for you, not just advising or telling you what to do; it is listening to the mother, trying to understand how she feels and helping her to develop self-confidence so that she can take control of the situation'. In this training, the WHO advises that all actors who come into contact with the mother should be trained in maternal counselling, which includes skills in breastfeeding management and communication skills for an effective therapeutic relationship.\u003c/p\u003e\u003cp\u003eIt has been asserted by certain authors that this training proposal is highly focused on the skills of professionals [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and not so much on the non-verbal signals of the mother, highlighting also that counselling is an aspect that is little known and valued by professionals, even though this area is little researched [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. According to the limited evidence available, the communication skills of professionals during the counselling process are poor [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], It is important that mothers have support for their self-efficacy and empowerment through professional interventions that are adapted to their individual needs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe main objective of this study is to explore the key aspects of the therapeutic relationship between professionals and the mother-baby dyad during BF counselling from a maternal perspective, as opposed to the communication skills framework recommended by the WHO during training in breastfeeding counselling [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].The WHO recommends [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] user consultation to improve effective interventions for breastfeeding promotion. Knowing what mothers value as important through participatory research designs will help us to better plan future training for the professionals who will care for them.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThe research was conducted under a qualitative descriptive design based on Glaser and Strauss' Grounded Theory [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In addition, the deductive research was guided by the Ecosystemic Model of Urie Bronfenbrenner's Theory due to its phenomenological approach [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This model is applicable to the complex functioning of the mother-baby dyad and the other determinants that condition the different experiences, environments and social conditions where perinatal care is provided. As a method of interaction with the participants, in-depth interviews and observation by the researcher were used.\u003c/p\u003e\u003cp\u003eThe Consolidated Criteria for reporting Qualitative Research guidelines (COREQ) were utilized to evaluate the quality of the qualitative research in terms of design, interviewing, analysis of results, and other pertinent aspects [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipant selection and sampling\u003c/h3\u003e\n\u003cp\u003eDescriptive exploratory qualitative studies are defined as those that provide information about an experience from the perspective of the people who live it, with the objective of increasing understanding [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The qualitative methodology allows the informants to volunteer to participate, as they are experts in the subject matter [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. To recruit the study population, the local breastfeeding support group was contacted and informed of the objectives and methodology of the project and approval was requested to inform its members about participation and to carry out information dissemination through their social networks. The snowball sampling procedure was used. This non-probability sampling by convenience made it possible to establish a pyramidal effect in the diffusion of the participation information. The inclusion criteria were mothers of infants born within the last five years who wish to offer EBF for the first six months and maintain it with complementary feeding. Exclusion criteria were mothers who have a language barrier. The indicators for assessing infant and young child feeding practices recommended by the WHO were used to classify the type of feeding according to the age of the infant [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMothers who agreed to participate in the study established communication with the research staff by e-mail. A phone call was then made to arrange the interview on the day and at the location agreed upon by the mother and the interviewer, in a quiet, reliable, and easily accessible location for the mother. The study sample was closed when data saturation was reached, and the collection of new information did not provide new insights into the research questions.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected through semi-structured individual interviews conducted by research staff with extensive training and experience in breastfeeding counselling and support. During the interview, mothers were invited to talk freely about key aspects of the study so that they could openly express their feelings, emotions, and experiences without being interfered with by the interviewer.\u003c/p\u003e\u003cp\u003eThe semi-structured interview, the content included a series of four open-ended questions based on the objectives of the study and the existing bibliography. In addition to the interview, sociodemographic and other relevant data on pregnancy, mode of delivery and breastfeeding were collected using an \u003cem\u003ead hoc\u003c/em\u003e data collection sheet.\u003c/p\u003e\u003cp\u003eAll interviews were recorded and stored in audio format after written consent was obtained from the participating mothers. They were then transcribed literally and identified with an alpha-numeric code to guarantee anonymity. Mothers were identified for the study using the pseudonym \"M\" followed by the order number of entry into the study, with \u0026ldquo;M1\u0026rdquo; being the first mother interviewed and \u0026ldquo;M16\u0026rdquo; being the sixteenth. The interviews were conducted between July 2023 and December 2024 and lasted on average 28.5 minutes (ranging from 43 to 17 minutes).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eAll interviews were recorded and subsequently transcribed verbatim and then analyzed using the method of thematic analysis proposed by Braun and Clark [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This method of analysis includes different phases of information processing, including: 1) The search for structures and meanings, through transcription, reading and annotation of general ideas; 2) Coding the content of the sentences, grouping the codes to generate categories and subcategories; 3) Creation, revision and definition of the themes according to the convergences of meaning, context or temporal circumstance of the previous categories; and 4) Preparation of the final results report.\u003c/p\u003e\u003cp\u003eTo ensure validity and reliability in the interpretation of the results, a triangulation process was employed by the study's authors, utilizing a comprehensive data set.\u003c/p\u003e\u003cp\u003eThe organization and interpretation of qualitative data was carried out using the ATLAS.ti- 25 software.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical aspects\u003c/h3\u003e\n\u003cp\u003e The study was authorized by the Bioethics Committee of the Cardenal Herrera CEU University (reference code: CEEI22/359). Participation in the study was voluntary, anonymous and confidential, with no language barrier hindering communication. Participants were provided with the study information sheet and informed of consent for their approval to participate and be recorded during the interview. This consent could be revoked at any time. The study complied with the ethical principles for medical research involving human subjects according to the 75th Declaration of Helsinki of the World Medical Association [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eParticipants characteristics\u003c/h2\u003e\u003cp\u003eAfter applying the selection criteria described in the methodology section, a total of 16 mothers agreed to participate in this study. The age range of the participating mothers was between 28 and 44 years (mean 35.7 years). Of the 16 women, 7 (43.7%) had a university education and the rest (56.25%) had intermediate education. Only one mother was unemployed at the time of the interview and two of them lived with their children without a partner. Nine of the mothers had only one child and the rest had two. The age of the last child ranged from 1 month to 3 years. The data pertaining to the subjects' birth and breastfeeding histories revealed that 6 of the 16 women (37.5%) underwent a caesarean delivery. Furthermore, 7 of these women (43.8%) indicated that they initiated breastfeeding within the first minute of life. In addition, 5 of the subjects (31.2%) were able to breastfeed within one hour of birth, while 4 of them (25%) required several hours to do so. Half of the women maintained exclusive breastfeeding during the first six months of life, all the mothers who reported their intention to breastfeed before delivery. The duration of breastfeeding was found to vary considerably after the first six months of the infant's life, with five cases of weaning occurring at the time of the interview. Of these five cases, three were attributed to the scheduling of the second pregnancy, while the remaining two were attributed to a lack of support and pain.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMain results\u003c/h3\u003e\n\u003cp\u003eThe following findings emerged from the process of analyzing the transcripts of the mothers' interviews, as described in the Methods section. The experience and perceptions of the mothers who were interviewed in this study were classified as 1 theme (maternal experiences in the birth and breastfeeding process), 4 categories and 7 subcategories. These categories and subcategories are described below in this section of results. The grouping, ordering and relationship of the main ideas was carried out following the theoretical bases previously exposed on the evidence related to the therapeutic relationship and communication [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and the ecological model [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMaternal experiences in the birth and breastfeeding process (Theme)\u003c/h2\u003e\u003cp\u003eThe texts describe the experiences of mothers during the process of childbirth and breastfeeding care and how they felt about everything that happened to them. They also mention what they value most in the care they receive and what they consider important to make the therapeutic relationship with the professional as satisfactory as possible in this process. Mothers have reported positive experiences and highlighted empathy and effective communication as crucial factors for a positive experience. The support provided by midwives and mothers' groups was received favorably. Concurrently, there were numerous negative experiences, including inadequate diagnosis, discourteous treatment, absence of empathy, and deficient information provision. Furthermore, the findings revealed that mothers held a perception of health professionals as lacking in knowledge regarding breastfeeding. This perceived deficiency in expertise engendered a state of distrust and skepticism among the mothers towards the support they sought. This situation gave rise to a range of emotions including frustration, anxiety and a sense of helplessness among the mothers. It was generally observed that women placed a strong emphasis on the necessity of care during breastfeeding that was personalized, respectful and well-informed (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMother's feelings and emotions (category 1)\u003c/h2\u003e\u003cp\u003eThis category comprises the feelings and emotions expressed by mothers during interviews. These may be triggered by healthcare professionals at specific moments of care, or by memories and circumstances of past events related to their previous experiences. Furthermore, the discourse of the mothers is characterized by the articulation of their personal sentiments and emotional responses, which are inextricably linked to their individual expectations and the unique circumstances that they encounter during the therapeutic relationship. The subjects have been classified as positive or negative, based on the literal description provided during the interview, to avoid any potential interpretations by the researchers (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSeven condensing units were identified as positive, highlighting the importance of feeling comfortable and secure in the breastfeeding process, as well as empathy and individualized attention from health professionals while providing emotional and educational support during the therapeutic relationship. The importance of feeling accompanied and empowered is also emphasized, as well as the positive valuing of effective communication and trust generated during this experience. Respectful interaction and closeness of care are perceived as key factors for the emotional and physical well-being of mothers during breastfeeding. The support group also generates positive feelings in the maternal account.\u003c/p\u003e\u003cp\u003eDuring the narratives there are situations resulting from mothers' interaction with health professionals. In these stories, mothers recount times when professional advice is absent, insufficient or ineffective, resulting in feelings of mistrust, sadness or disappointment in the professional support system. They have felt that breastfeeding was in danger because of pain or lack of information, and they have felt very lonely, helpless, anxious and afraid. No negative experiences are mentioned when care is provided in the support group.\u003c/p\u003e\u003cp\u003eMothers\u0026rsquo; express feelings of low self-confidence, guilt or feeling that they are bad mothers when the professional does not consider their lack of skills, insecurity in maneuvers or knowledge. They feel that they are judged and that the staff makes it difficult for them to assert their maternal role, which lowers their self-esteem.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCategory that describes feelings and emotions (category 1)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubcategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCondensing units. Quotations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e\u003cp\u003eFeelings and emotions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMEM positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEncouragement.\u003c/b\u003e \u003cem\u003eM7\u003c/em\u003e: \u0026lsquo;My paediatrician tells me the truth; I changed paediatricians between my first (son) and second (son). She reassures me and encourages me, she encourages me to keep going, even with the older one. My current paediatrician encourages me, the previous one didn't, she neither encouraged nor discouraged me\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSecurity, peace of mind.\u003c/b\u003e \u003cem\u003eM9\u003c/em\u003e: \u0026lsquo;I felt safe, it gave me security, it gave me peace of mind, even though it might not work out the theory that we had. But I had that security and that peace of mind that I knew that if I needed something, he was going to be there and he was going to help me\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eComfort, closeness\u003c/b\u003e. \u003cem\u003eM11\u003c/em\u003e: \u0026lsquo;They are very good feelings because I feel very safe and I feel especially comfortable when I have sessions with her, because she gets involved, helps you, comments, does everything with affection and in the end also makes you feel accompanied. She focuses a lot on you as a person\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEmpowerment, confidence.\u003c/b\u003e \u003cem\u003eM4\u003c/em\u003e: \u0026lsquo;My paediatric nurse gave me that confidence. I felt like I was always doing everything right; she never said anything that made me worry about my son's health. All that gives you strength and confidence, reassures you, and encourages you to keep going\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003eMEM negative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eAnxiety and worry, confusion, misunderstanding\u003c/b\u003e. \u003cem\u003eM8\u003c/em\u003e: \u0026lsquo;It's just that my nipples aren't flat, they're flatter than normal. So, the girl gave me a nipple shield, and it worked fine. Two hours later we had the same problem again. I felt like they were giving me solutions to my distress and concerns, but I felt that something wasn't right\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eAnxiety and stress, lack of support, helplessness.\u003c/b\u003e \u003cem\u003eM 11\u003c/em\u003e: \u0026lsquo;Well, the truth is that it's pretty bad, I mean, on top of that, no one, I mean, no one offers you help, the help they offer you isn't what you need, and on top of that, you've just given birth, literally two hours ago, and you ask yourself, 'Well, what do I do now? It's a feeling of helplessness!\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePain, disappointment, frustration.\u003c/b\u003e \u003cem\u003eM4\u003c/em\u003e: \u0026lsquo;Honestly, I tell you, the predominant emotion was disappointment. With the second one, about which I already had much more information, I felt a little disappointed, because I realised that much of the advice, they gave you or the way they told you things, contradicted each other among the healthcare staff\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eLoneliness, abandonment, resignation\u003c/b\u003e. \u003cem\u003eM7\u003c/em\u003e: \u0026lsquo;With the first one, it was absolute loneliness, and with the second one, I suppose experience counts for something, so the loneliness was less, but it was almost me, with my convictions, who was so sure that I would have gone to India and come back if I had had any problems\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eJudged.\u003c/b\u003e \u003cem\u003eM13\u003c/em\u003e: \u0026lsquo;It made me feel like a bad mother. I was trying to bottle-feed her. And then she [the nurse] came in and said, \u0026ldquo;Leave it to me, you don't know how to do it\u0026rdquo;. \u003cem\u003eM6\u003c/em\u003e: \u0026lsquo;Yes, I can tell you that I left (the health centre) crying, I felt like an idiot, they made me feel that way, they made me feel like I had no idea what I was doing, and maybe it was true, I can tell you that, but I go there precisely to be taught and helped\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eDiscomfort, anger, unpleasant moment not asking permission to touch\u003c/b\u003e. \u003cem\u003eM2\u003c/em\u003e: \u0026lsquo;And then (the nurse) grabbed my breast, grabbed my breast, grabbed the baby's head and forced him to do it, a bit like saying, \u0026ldquo;That's where it has to be\u003cem\u003e\u0026rdquo;\u003c/em\u003e. I didn't like her attitude. She should have said, \u0026ldquo;I'll explain it to you\u0026ldquo;, and asked first, \u0026ldquo;Can I hold the baby? Can I put him on my chest?\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eFear, sadness and depression, guilt, vulnerability\u003c/b\u003e. \u003cem\u003eM6\u003c/em\u003e: \u0026lsquo;Yes, I can tell you that I left (the health centre) crying, I felt like an idiot, they made me feel that way, they made me feel like I had no idea what I was doing, and maybe it was true, I can tell you that, but I go there precisely to be taught and helped. losing my milk supply. So, I tried everything I could, but no, no, he wouldn't latch on or he would only latch on to one breast, and the breast he latched on to hurt\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eMEM: Mother\u0026acute;s emotional moments\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTherapeutic relationship (category 2)\u003c/h2\u003e\u003cp\u003eParticipants shared their experiences during the therapeutic relationship with health professionals (mainly midwives and pediatricians), highlighting the importance of feeling listened to, supported and validated in their emotions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticular\u0026rsquo; problems were reported in the study, such as difficulty in initiating breastfeeding, difficulties in latching on and experiences with pain when breastfeeding. A significant proportion of maternal comments focused on a perceived lack of attention to the needs and concerns inherent in the maternal role, which often led to feelings of anxiety and loneliness among mothers. Some mothers found comfort in support groups and professionals who demonstrated a genuine interest in their emotional and physical well-being. In contrast, other mothers reported feeling neglected or with little support from health staff.\u003c/p\u003e\u003cp\u003eThe recurrent theme of knowledge and training of professionals was also noted, with some participants citing the lack of updating on breastfeeding issues by pediatricians and nurses as a cause of doubt and frustration. The utilization of nipple shields to alleviate discomfort is prevalent, suggesting a deficiency in professional expertise.\u003c/p\u003e\u003cp\u003eEffective communication and empathy were key factors in generating positive experiences. In contrast, the absence of such skills led to feelings of helplessness and mistrust. Maternal reflections show that sympathetic care and a willingness to listen with personalized care are fundamental to their emotional health and their perception of efficacy and supportive experience, as well as to ensure a successful and satisfying breastfeeding process.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eWomen\u0026acute;s support network (category 3)\u003c/h2\u003e\u003cp\u003eMothers feel more supported and understood in support groups with other mothers than with health professionals. They share their experiences and feel supported in their breastfeeding decisions. Interaction with other parents through WhatsApp groups and breastfeeding workshops gives them comfort and help. Sometimes they feel that health professionals do not have all the tools they need to help, so they turn to external specialists. Empathy and support from the community of mothers are essential to feel empowered and confident in their decisions. Lack of information and visible references in the social environment can create discomfort and the need to unlearn long-held beliefs about breastfeeding (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the accounts of some women, reference is made to partners and families. The term 'breastfeeding support' refers to the assistance provided to mothers in upholding and sustaining their decision to breastfeed, in making collaborative decisions regarding matters pertaining to pregnancy and childbirth, and in engaging in collaborative efforts, both in the execution of procedures and in challenging circumstances, with the objective of promoting and maintaining breastfeeding.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCategories that describe therapeutic relationship and women\u0026acute;s support network (category 2 and category 3)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubcategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCondensing units. Quotations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eTherapeutic relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eKeys to care according to the mother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eListening, support, trust, validation\u003c/b\u003e. \u003cem\u003eM14\u003c/em\u003e: \u0026lsquo;I think all communication skills are important, really. But feeling listened to, I think that has also helped me. Not minimising my problems, not feeling like they're silly. Being listened to, having time dedicated to you, is important. Then, the feeling of support and training, and then trust. Feeling supported and listened to, and I can really relate to that. Because in the end, I think that just listening to me is a way of supporting me\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePersonal attention, understanding, availability\u003c/b\u003e. \u003cem\u003eM10\u003c/em\u003e: \u0026lsquo;After giving birth, she looked after me. She was supposed to see me once, but she saw me three times. I wrote to her through the app and she replied to the same day. They really helped me, they had a different way of communicating, more affectionate, more intimate. They give you the feeling that they are less in a hurry, even though they may be just as busy, but they make you feel that they are less rushed. They see you; they help you get settled, they make suggestions\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eClear communication.\u003c/b\u003e \u003cem\u003eM15\u003c/em\u003e: \u0026lsquo;No, the second time it was very clear to me. No one told me anything clearly, neither the midwife nor the hospital. .as it was an emergency caesarean, no one told me anything, they just said: \u0026lsquo;Put it on!\u0026rsquo; And I said, \u0026ldquo;But how? I can't move, my whole-body hurts\u0026rdquo;. I cried. They said, \u0026ldquo;Don't cry, just put him down!\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eKindness and gentleness, respect, empathy.\u003c/b\u003e \u003cem\u003eM13\u003c/em\u003e: \u0026lsquo;The girl I really liked was the neonatal nurse; she was so sweet. She said, \u0026ldquo;Look, can you let me? If you want, if you can lift your arm a little, I'll put the pillow here\u0026rdquo;, everything with a lot of respect, a lot, nothing abrupt. The other girl picked him up, well, of course, you pick up babies every day and you pick them up with one hand, but when I pick up my son, I think he's going to break, but this neonatal nurse was so sweet. She picked him up, asked my permission, \u0026ldquo;Look, move him a little bit here, me a little bit there\u0026rdquo;. I don't know, she was so peaceful. The other one, she wasn't aggressive, but she gave off an aggressive vibe\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEthical treatment, learning.\u003c/b\u003e \u003cem\u003eM6\u003c/em\u003e: \u0026lsquo;Yes, I'm telling you, I left there crying. I felt like an idiot... like I had no idea what I was doing, and maybe that was true, I'll tell you that too, but I went there to be taught and to be helped\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eWomen\u0026acute;s support network\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePeer support\u003c/p\u003e\u003cp\u003eParents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eComfort, listening, a warm space\u003c/b\u003e. \u003cem\u003eM7\u003c/em\u003e: \u0026lsquo;I arrived at the support group for mothers and found it to be a relaxed space. Although the room was untidy, it felt like a warm environment. I felt listened to and understood, because until then I had never felt understood, and I felt that my emotions were valid. So here I am, it was what I needed\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSharing experiences, understanding and support.\u003c/b\u003e \u003cem\u003eM10\u003c/em\u003e: \u0026lsquo;The association, the WhatsApp group of mothers, the mothers who wrote to me privately to tell me about their experiences, how they had managed to help and support me, and the mothers in the group we have formed in the breastfeeding workshop at the health centre, we have created a wonderful tribe. They have helped me simply by being in a place where you can let off steam and talk about your experience\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSeeking support\u003c/b\u003e. \u003cem\u003eM10\u003c/em\u003e: \u0026lsquo;For me, being in this group and being able to read about all the problems people have and the solutions you give them gives me a lot of peace of mind, also because I see that this is something that is not seen in the world. \u003cem\u003eM14\u003c/em\u003e: \u0026lsquo;She came to the mothers' group looking for support, comfort and sharing\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMutual support, collaboration, decision-making.\u003c/b\u003e \u003cem\u003eM4\u003c/em\u003e: \u0026lsquo;I feel very supported by the staff, but what I really need is the support of my partner and my family. Whether the paediatric nurse supports me or not, I really don't care, because I'm going to do what I want with breastfeeding. What I do need is the support of my loved ones\u0026rsquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare environment (category 4)\u003c/h2\u003e\u003cp\u003eIn the maternal comments, there are references to the conditions of care depending on whether it is in the public sector (hospitals and primary health centers of the public health network) or in the private sector (private clinics specialized in parenting care). Both contexts are part of the network of maternal care in the health sector and are influenced by the human and material resources available to women (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMothers experience frustrations stemming from the lack of personalized care and limited resources in public administration. A growing demand for greater availability, training and resources in the health system has been observed. Unfulfilled appointment requests and a perceived lack of patience to deal with them have also been identified. In addition, it has been identified that limited time in consultations can make care mechanized and depersonalized.\u003c/p\u003e\u003cp\u003eMothers also expressed gratitude for the availability and attention of some midwives. They commented on the existence of a certain conflict of interest between the professionals working in both sectors. Mothers expressed dissatisfaction with the care received in public environments compared to private health care, where they found the diagnosis and treatment of their children to be quicker and of higher quality. The importance of effective communication and the provision of personalized care, particularly in the context of breastfeeding and mental health issues, is emphasized. The absence of updating and the prioritization of concrete solutions by certain health professionals has engendered mistrust and discontent among mothers, who hold the support and empathy provided by private midwives and specialists in high regard.\u003c/p\u003e\u003cp\u003eSome informants detect a conflict of interest in the referral of public sector professionals to private clinics, involving an expense that not all families can afford after the arrival of a baby.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCategories that describe Healthcare environment (category 4)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubcategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCondensing units. Quotations.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eHealthcare environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003ePublic sanitary environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMechanised care, fast care, work stress.\u003c/b\u003e \u003cem\u003eM4\u003c/em\u003e: (talking about the consultation at the health centre) \u0026ldquo;You know that if you go when you're in a hurry and they're rushing and don't say anything to you, even if they don't say it, you somehow know that there's not much time for the consultation. Besides, you know there are always people waiting. One person leaves, another comes in. ... No one asks you any questions. You get the feeling that it's more like, \u0026lsquo;Come on, let's weigh the baby, measure him, give him his vaccinations, and how is the baby feeding?\u0026rsquo;, and that's it\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePerception excessive workload.\u003c/b\u003e M 7: (talking about the midwife in the postnatal ward) \u0026ldquo;... the thing is, she could only help you for five minutes. Because she had to see many more patients throughout her shift. So, of course. I remember it like this: \u0026lsquo;Let's talk, bye, bye, bye.\u0026rsquo; I'm not asking for a one-hour consultation, but I am asking for at least 15 or 20 minutes\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eDiscontinuity of care, lack of availability, lack of training, inexperience.\u003c/b\u003e M 11: \u0026ldquo;... But in the ward he didn't want to breastfeed, and it hurt a lot when he did. So, I called the nurses, but as it was Sunday night, all the staff were paediatricians... So, until the next day, when the midwife didn't come, we tried to get her to latch on, but she was in a lot of pain all night, and when her shift ended, she left and didn't want to try again, so we were left in the same situation\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eConflict of interest, difficulty accessing care\u003c/b\u003e. M6: \u0026ldquo;In a public place... maybe she could have helped me more, but it's not her job as a midwife, but as a physiotherapist... Because I know she's a physiotherapist, and when I went there with the problem and everything, maybe she could have looked at it and... Sure, sure, but it's not her job\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eKnowing how to refer, lack of staff\u003c/b\u003e. M2: \u0026ldquo;Let's see, first of all. That the professional, perhaps it's not difficult, but that they are trained in everything that currently exists, and if they don't know, that they tell me no, that they are not trained, but that there is a specialised centre that can help me. In other words, honesty in admitting that they don't know, and that's the option. And then, above all. Let's see, what I've found lacking in the National Health Service is the lack of resources, that is, if a physiotherapist doesn't do it, you have to pay for it yourself. So it's like, yes, thank God I have money, we work and I can afford it, but...\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eProtocols\u003c/b\u003e: M 10: \"They rely heavily on protocols... but in my view, that's not incompatible with personalising care. So, when I ask them for certain care based on scientific evidence... well, they're not used to that. They're used to following a protocol, and when you ask them for something that's not in their protocol, they feel a bit lost. That's my feeling. And then it bothers them when you challenge them, even politely, because I think they're more used to telling patients what to do and the patient obeying.\"\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePrivate sanitary environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eProblems with tongue-tie detection, exclusivity of private care, difficulty accessing care.\u003c/b\u003e M4: \u0026ldquo;The second time I stopped breastfeeding, tongue-tie problems, etc. Well, gas, pain, tongue-tie that no one in the public sector knew how to detect. Well, I had to resort to the private sector thanks to my knowledge. Otherwise, it would probably have been a failed breastfeeding experience, because, well, we all know what it means to have ankyloglossia\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eProvision of private help, paediatric specialities.\u003c/b\u003e M 16: \u0026ldquo;Of course, I was in incredible pain. And then we also went to an external breastfeeding consultant (from the private sector), because we had another crisis two days later, and we didn't understand anything, we didn't know how it had happened or why it was happening, and then, ten days later, I had my first blockage...And as I had already read a lot, someone had asked about it in the (mothers' support) group and they explained it to her, and she (the private midwife) gave me some links to look up on the Internet.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eHigh cost.\u003c/b\u003e M 9: \u0026ldquo;Not at X (name of private physiotherapy clinic), they did give him tongue strengthening sessions, which did help him to latch on properly, but after the third session I felt that it was pointless, that we were just sitting there, paying a fortune because it was so expensive, and the child wasn't doing anything\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePrivate mental health.\u003c/b\u003e M 10: \u0026ldquo;In the end, because I asked the midwife at the health centre, they referred me to mental health, but they took so long to call me that I ended up going private, also to my psychologist\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe analysis of the results shows that existing literature presents important similarities in the phenomenon studied. The mothers in our study emphasize the importance of personalized treatment and the need to improve professionals' training in breastfeeding and counselling skills. Research in the field of maternal experiences in childbirth and breastfeeding shows, as in our results, that mothers value qualified breastfeeding support, and for this support to be effective, it is important to focus on the individual needs of each mother and improve the training of support staff [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41 CR42 CR43 CR44\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eYang Y et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], in their recent review on the subject, call for the optimization of peer support services and the strengthening of their role in promoting breastfeeding. In our study, mothers describe these spaces as safe and supportive places for breastfeeding, where there are no communication or relationship problems. In contrast, there are repeated instances of conflict and communication problems between professionals and the mothers interviewed.\u003c/p\u003e\u003cp\u003eAccording to the meta-analysis by Chesnel MJ, Healy M, McNeill J [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] which analyzed the opinions of 368 participants in 21 articles, it is clear that the potential of each experience to facilitate or inhibit breastfeeding is a complex and changing process that depends on the context, highlighting the importance of the mother's perception of the personalization of the process as a key element in ensuring successful breastfeeding. Our sample of accounts emphasizes the need for personalization of the process and the need to feel that care is tailored to the special needs of each mother-baby pair and their contexts.\u003c/p\u003e\u003cp\u003eResearch examining the impact of communication skills from maternal and professional perspectives is limited [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. According to Burns [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], mothers' perceptions of their caregivers' level of knowledge and training can influence their trust in the caregiver Mothers worry about whether the advice given will solve the problem or whether it is appropriate at the time it is given. This is a source of mistrust that also appears in our study, and which ultimately determines the relationship of trust with that professional, even leading to the mother leaving the care system to seek alternatives such as private sector lactation specialists or informal support groups. According to Patel S [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] this situation could be optimized by referring mothers to accredited lactation consultants, such as IBCLCs (International Board-Certified Lactation Consultants). This procedure would lead to more favorable results in the resolution of breastfeeding problems, since, according to the available evidence, the level of knowledge of accredited consultants exceeds that of standard practitioners [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eAfter a thorough examination of the results of the analysis of the maternal narrative, the following conclusions can be drawn.\u003c/p\u003e\n\u003cp\u003e1. The mother\u0026apos;s perception of the level of knowledge and skills acquired and demonstrated by the professional in the management of breastfeeding can influence the mother\u0026apos;s relationship of trust with the professional and her concept of herself as a mother. Mistrust generates feelings of guilt, a breakdown in trust and, in some cases, a search for alternative care in the private sector.\u003c/p\u003e\n\u003cp\u003e2. The most important aspects of communication are empathy, accessibility, a relationship of respect, closeness and mutual trust before counselling, and friendly treatment.\u003c/p\u003e\n\u003cp\u003e3. It is important for the mothers in our research to feel that they are receiving personalized treatment, with opportunities during consultations to be asked, beyond the breastfeeding situation, about their physical and emotional state and other circumstances that determine their motherhood and parenting process.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e We would like to thank the group of mothers who gave their time and trust to carry out this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate and publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was authorized by the Bioethics Committee of the Cardenal Herrera CEU University (reference code: CEEI22/359). Participation in the study was voluntary, anonymous and confidential, with no language barrier hindering communication. Participants were provided with the study information sheet and informed of consent for their approval to participate and be recorded during the interview. This consent includes the publication of the information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe anonymised text material collected during the interviews with the mothers is archived and available for consultation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThis study was conducted without financial support from public, private, or non-profit institutions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of interest: \u003c/strong\u003eThe authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eL.M. participated in the design of the first draft of the manuscript, carried out the intervention, data analysis and collaborated in the editing of the final manuscript. G.I. co-wrote the first draft of the manuscript, directed the data analysis, and collaborated in the implementation of the intervention. M.E. collaborated in the data analysis. E.V. participated in the study design, directed the implementation of the intervention and data analysis, and edited the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAffiliations: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarina Leal-Clavel\u003csup\u003e1 *\u003c/sup\u003e, In\u0026eacute;s Gonz\u0026aacute;lez-S\u0026aacute;nchez\u003csup\u003e\u0026nbsp;2\u003c/sup\u003e, Esther Manche\u0026ntilde;o-Maci\u0026aacute;\u003csup\u003e3\u003c/sup\u003e, Vanesa Escudero-Ortiz\u003csup\u003e3\u003c/sup\u003e.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDepartment of Nursing and Physiotherapy, School of Health Sciences, Universidad Cardenal Herrera-CEU, CEU Universities, 03203 Elche, Spain\u003c/li\u003e\n \u003cli\u003eNursing Subdivision. Hospital General Universitario Dr. Balmis-Alicante. Instituto de Investigaci\u0026oacute;n Sanitaria y Biom\u0026eacute;dica de Alicante (ISABIAL Grup 23. Innovation in nursing care), Alicante, Spain.\u003c/li\u003e\n \u003cli\u003eDepartment of Biomedical Sciences, School of Health Sciences, Universidad Cardenal Herrera-CEU, CEU Universities, 03203 Elche, Spain.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHorta BL, Loret de Mola C, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and meta-analysis. Acta Paediatr. 2015;104:30\u0026ndash;37. Medline: 26192560 doi: 10.1111/apa.13133\u003c/li\u003e\n\u003cli\u003eVictora CG, Bahl R, Barros AJD, Fran\u0026ccedil;a GVA, Horton S, Krasevec J, Murch S, et al. 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Best practice information sheet: Women\u0026apos;s perceptions and experiences of breastfeeding support. Nurs Health Sci. 2012;14(1):133\u0026ndash;135. Medline: 22339720. doi: 10.1111/j.1442-2018.2012.00679.x. \u003c/li\u003e\n\u003cli\u003eBurns E, Schmied V. \u0026quot;The right help at the right time\u0026quot;: Positive constructions of peer and professional support for breastfeeding. Women Birth. 2017 Oct;30(5):389\u0026ndash;397. Medline: 28359753. doi: 10.1016/j.wombi.2017.03.002. \u003c/li\u003e\n\u003cli\u003eMichaud-L\u0026eacute;tourneau I, Gayard M, Lauzi\u0026egrave;re J, Beaudry M, Pascual LR, Chartier I, et al. Understanding the challenges related to breastfeeding education and barriers to curricular change: A systems perspective for transforming health professions education. Can Med Educ J. 2022;13(3):91\u0026ndash;104. Medline: 35875442; doi: 10.36834/cmej.73178. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast Feeding consultation, Communication skills, Counseling breastfeeding, Mothers, Professional-Patient Relations, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-8157994/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8157994/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e. The primary objective of this study is to explore the key aspects of the therapeutic relationship between professionals and the mother-baby dyad from the mother's perspective. The World Health Organization advocates participatory research to enhance the efficacy of breastfeeding promotion interventions. A comprehensive understanding of the factors deemed significant by mothers is instrumental in the effective planning of communication skills training for the professionals entrusted with their care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e. The present study employed qualitative content analysis, drawing upon Glaser and Strauss' grounded theory, and encompassed in-depth interviews and participant observation. The study comprised mothers of infants born in the last five years who had expressed a desire to offer exclusive breastfeeding for a period of six months. Participation was voluntary, anonymous and without language barriers. The analysis was conducted utilizing the software program Atlas.ti v25.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Theme 1: Maternal feelings and emotions during birth and breastfeeding. Category 1: Maternal emotional moments: positive feelings such as encouragement, confidence and gratitude, and negative feelings such as fear, guilt, loneliness and misunderstanding. Category 2: The therapeutic relationship: mothers value empathy, respect, active listening and personalised treatment. Category 3: Healthcare environment: barriers such as mechanised care and lack of staff are perceived in the public system, while limited access and high cost are perceived in the private system. Category 4: Support network: The importance of support groups for mothers and their partners in terms of decision-making and emotional support is emphasised.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Mothers' perception of the knowledge and skills that professionals have acquired and demonstrated in the management of breastfeeding influences their confidence. The most important factors are empathy, accessibility, respect, closeness, trust and a personalised approach prior to counselling. They value accessible and reliable spaces where they can discuss their physical and emotional health.\u003c/p\u003e","manuscriptTitle":"Maternals´ experiences and perceptions in communication relationship with health professionals during breastfeeding counseling. A Qualitative study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 05:44:28","doi":"10.21203/rs.3.rs-8157994/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4bc517a1-a390-44e6-803d-fb1176019da8","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T11:54:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 05:44:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8157994","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8157994","identity":"rs-8157994","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}