Would a Planning Card Help New Mothers Achieve their Breastfeeding Goals? Evidence from Focus Groups of Mothers and Health Professionals

Would a Planning Card Help New Mothers Achieve their Breastfeeding Goals? 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Evidence from Focus Groups of Mothers and Health Professionals Alix Aitken-Arbuckle, David Comerford, Susannah Boardman, Ailin Chen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6985799/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Breastfeeding has multiple health benefits for infants and their mothers. Extensive educational and promotional efforts are made by public health initiatives to encourage mothers to initiate and maintain breastfeeding, yet many women experience difficulties and high rates of drop-off at 6-8 weeks of life are noted globally. Development of a breastfeeding planning card focusing on solving common breastfeeding problems may help parents achieve their breastfeeding goals. As part of a feasibility study for implementing the card, focus groups were used to explore the acceptability and feasibility of implementing the planning card delivered by midwives during routine antenatal care. Methods Two groups of participants were recruited: one comprising mothers with lived experiences of breastfeeding; and one with health professionals from midwifery, health visiting and infant feeding areas. Focus group discussions aimed to explore acceptability of using a breastfeeding planning card including content, and delivery for pregnant women and feasibility of delivery within routine antenatal care. The focus group aimed to inform reflections and suggest adaptations to the card content and use. Data were analysed using a framework analysis, paying close attention to intervention vulnerabilities and delivery practicalities. Results: Barriers and facilitators of disseminating the card and perceived utility were discussed in focus groups. Overall perspectives were positive regarding content and delivery of the card including content clarity and relevance. Professionals raised some concerns about discrepancies in clinical practice and mothers highlighted conflicting messages which did not align with their experiences of care received. Most interesting were discussions supporting delivery of 'realistic' information to appropriately prepare mothers for breastfeeding. Conclusions Evaluation of acceptability and feasibility of the card was a vital step to address potential barriers and facilitators to implementation. Discussions with targeted groups addressed key questions and supported further card development. Importantly, desirability of this support tool providing realistic breastfeeding information was confirmed by professionals and mothers. The card content was adapted for further testing based on discussions. Breastfeeding Planning Card Content and Design Perinatal Care Health Action Process Approach Infant Feeding Intervention Figures Figure 1 Background Promoting good health in early years is one of 6 public health priorities identified by the Scottish Government [1]. Nutrition is key. The World Health Organization recommends that infants are exclusively breastfed for the first six months of life [2]. Infants who are breastfed enjoy better health and developmental outcomes than formula-fed infants [3]. These benefits increase with breastfeeding duration and exclusivity. Additionally, breastfeeding has substantial health benefits for mothers, associated with reduced incidence of breast and ovarian cancers, osteoporosis and diabetes. It is also beneficial for uterine involution, weight loss, natural contraception [4,5] and has psychosocial benefits including reduced stress and postnatal depression and increased postnatal maternal well-being [6]. Scotland has low rates of breastfeeding initiation and duration by international standards; just 68% of newborns are breastfed, dropping to 49% at 6-8 weeks postpartum [7]. In 2018, the Scottish Government identified rates of breastfeeding drop-off in the postpartum period as a particular concern and its 'Diet and Healthy Weight Delivery Plan' states a commitment to reduce drop-off in breastfeeding rates at six to eight weeks after birth by 10% by 2025 [8]. This current study builds on previous work using a theory-based approach to reduce breastfeeding drop-off. Behavioural science theories help us to understand and improve health promoting behaviours such as breastfeeding by specifying key influences and determinants and their relationship with behaviours. Both initiating and maintaining behaviours are important for good health, and different factors might be at play in these stages of behaviour change [9]. Health Action Process Approach (HAPA) theory distinguishes between two stages that determine whether a behaviour is likely to be maintained: (a) a motivational stage where people form an intention to act, and (b) a volitional stage where people form and enact concrete plans to carry out the intended behaviour [10]. Public health campaigns in Scotland have generally addressed the motivational stage by providing information on the benefits to mother and baby of breastfeeding. For example, NHS Scotland has published posters (“Breastmilk Benefits” and “Breast milk versus Formula”) and disseminated booklets (“Ready Steady Baby” and “Off to a Good Start” [11]). Also, the Scottish Government has sought to address social barriers to breastfeeding via the Breastfeeding Act, 2005, setting out a legal right to breastfeed in public places. Available evidence suggests that these public health campaigns have proven successful at promoting breastfeeding intentions and increasing initiation [12]. Where the Scottish public health community has been less successful is in the 'enactment' or volitional stage of the HAPA model. Many women start breastfeeding but quit soon afterwards [12,13,14]. A recent study sought to address that gap. Researchers delivered a breastfeeding planning card to women who were at least 36 weeks pregnant. The planning card reduced drop-off from breastfeeding four-fold[15]. This planning card intervention could have substantial effects on breastfeeding maintenance if scaled-up across the Scottish population and would have applicability in other contexts where breastfeeding drop-off is a problem. The majority of drop-off in Scotland occurs in the first two-weeks post-partum and 86% of mothers report that they would have liked to have breastfed for longer [12]. These statistics imply that new mothers face practical difficulties implementing their intentions to breastfeed. One mechanism through which the card might have its effects is by enhancing breastfeeding self-efficacy, a key component of the HAPA model related to putting behavioural intentions into action [16]. To the extent that breastfeeding is a 'natural' human behaviour, new mothers may expect it to come naturally i.e. effortlessly and without complications. That expectation could lead mothers to conclude that any difficulties they experience are non-normal. The card enhances self-efficacy by informing mothers that it is normal to experience some difficulties when breastfeeding and so reassures that there is nothing ‘wrong’ with them or their baby. Additionally, the card provides 'troubleshooting' tips (coping planning) which may give mothers a sense of increased mastery and control over the breastfeeding process supporting enactment and maintenance of breastfeeding behaviours [16]. Methods This study was developed to determine the feasibility of delivering the planning card previously used as a research tool, as part of standard antenatal care in line with NHS and WHO/Unicef (2014) Baby Friendly Initiative recommendations [17]. These standards for maternity, neonatal and community care include promotion of breastfeeding. We first elicited opinions from a Co-Production Research Team (see below) to devise the questions used in focus groups. These questions focused on desirability, design and content. Two focus groups were held, one made up of midwives, health visitors and infant feeding coordinators, the other comprising breastfeeding women who had recently given birth. This study presents a thematic analysis of findings from these focus groups, exploring perceptions of the barriers, facilitators and benefits of antenatal delivery and use of the planning card. Study Aims 1. To assess the perceived suitability of the design and content of a planning card to support breastfeeding, including motivational (breastfeeding planning intentions) and volitional ('if-then' coping planning) aspects of the card content. 2. To assess whether midwives and mothers consider it feasible, acceptable and desirable for the planning card to be delivered during standard antenatal care. 3. To determine the most efficient protocol for delivery of the card i.e. how can delivery of the card complement existing midwifery practice? Design This qualitative study was part of a wider feasibility study and designed to maximise study quality and impact [18]. It included two focus groups with practitioners and those with lived experience of breastfeeding. The focus group discussions were semi-structured using tailored topic guides for mothers and midwives [ Appendix 1] prompting discussion of specific topics related to acceptability and feasibility of delivering the breastfeeding planning card in routine antenatal care. Ethics The study was conducted in accordance with principles of the International Conference on Harmonisation Tripartite Guideline for Good Clinical Practice (1995)[19]. These focus on trial quality. The study protocol was approved by University of Stirling Ethics Committee (NICR 2022 8214 6595). The UK health service IRAS ethics application was reviewed by NHS Black Country Research Ethics Committee and by ACCORD NHS Lothian Research and Development office [17-8-22, 22/WM/0168] Settings and participants This study was conducted in a large health board in central Scotland with a birth rate of approximately 9,000 per year. Focus groups were held in a community health and social care partnership site where community services are offered. A Co-Production Research Team was established during study development to support aspects of study design and recruitment. This comprised five individuals: two practising midwives who had worked in the health board and one infant feeding practitioner, one midwife and one student midwife from a different health board. The team met online over several months prior to data collection to aid development of the intervention and again following the focus groups to support analysis of findings. An Advisory Group comprising two senior academics - health psychologists experienced in behavioural research methods also oversaw the conduct of the research, meeting the research team three times throughout the duration of the project to advise on design, data collection, analysis and dissemination. Focus Group Participants Recruitment Participants for both groups were recruited using purposive sampling techniques. The health professionals were recruited through email advertisement to their NHS email accounts via their clinical managers. These asked any interested parties to contact the research team directly to participate in the focus groups. Women with lived experience of breastfeeding were recruited via posters displayed in local infant feeding support groups. Interested parties were asked to contact the research team directly if they wanted to participate. The Participant Information Sheet (PIS) was sent to all participants via email upon expressing interest in the study, allowing them sufficient time to review it before making a decision about participation. An information pack containing the PIS and consent form was distributed to participants on the day of the focus groups and signed consent forms were collected by a researcher. Focus Groups Both focus groups were conducted on the one day in January 2023. The first was with health professionals and the second was with women with current or very recent lived experience of breastfeeding. Seven health professionals were recruited, two midwives, one student midwife, one health visitor and three infant feeding specialists. The healthcare professionals' focus group lasted 64 minutes and took place during lunch time at a local health and social care outpatient base. Six women attended the focus group which lasted 65 minutes and was held in the afternoon in the same outpatient base. Participants were all white-Scottish, two had more than one child. Following the focus group, a £20 voucher was emailed to participants to compensate for their time and travel costs. Focus group interview schedules [Appendix 1] were developed collaboratively by the co-researcher group and advisory team and investigated the acceptability, desirability, design and content of the breastfeeding planning card. Both groups were conducted by experienced facilitators and midwives in the research team. They were audio-recorded and transcribed verbatim. During the focus groups, participants were introduced to the study by explaining the rationale based on previous work. Professionals were also asked how the card content 'fits' with existing information provision and practice, informed by the WHO/UNICEF Baby Friendly Initiative, and any potential harms from its use. Planning Card All participants were then given a copy of the Breastfeeding Planning Card to review. This was presented in hard-copy as shown in Figure 1. It was proposed that the final version would be 'credit card' sized, and this was discussed in the groups. The QR code linked to local breastfeeding support services. Data analysis Analysis was conducted using NVivo [20] and Microsoft software. Transcripts were analysed simultaneously. The Framework Analysis Approach was applied to the transcripts to draw out key themes and discussion [21]. A framework of categories was developed in agreement with the research team, focusing on the key areas of interest outlined in the focus group interview schedule and research objectives. Subsequently, the data were assigned to the framework for initial coding. This framework was adapted to ensure new codes or themes were included. Initial coding was conducted by a midwife researcher using an inductive approach, and the codebooks were reviewed by the research team to refine themes and conduct further coding. The analysis involved cross-referencing codes, selecting illustrative quotes, and facilitating comparisons between themes. The Framework Analysis provided a structure and enabled exploration and comparison of similarities and differences in perspectives between healthcare professionals and mothers. As part of the analysis process the research team discussed any fundamental problems regarding perceived feasibility and acceptability of the card which may affect use in practice. These and identified mechanisms of action were noted and considered during the analysis [18]. Results The findings highlighted aspects of the perceived acceptability, desirability, design and content of the breastfeeding planning card. Health professionals and women with breastfeeding lived experiences discussed these aspects in detail, reflecting on the content and utility of the card and the process of embedding the card within wider antenatal routine care. Potential weaknesses in the card design were identified. Discussions identified some key mechanisms of action which confirmed a priori theories of how the card could support positive breastfeeding behaviours. The following themes and subthemes were identified as shown in Table 1. Table 1: Summary of Focus Group Themes and Sub-themes Theme Sub-theme 1. Acceptability of the card 1.1 Encouragement and relevance 1.2 Effect on breastfeeding experience: Positive enhancement 2. Content and design 2.1 Clarity of card content: visual communication and realistic experience 2.2 Desired information: Engaging design and promoting positive experience 2.3 Potential misinformation or harm 2.4 Validation - mechanism of action 3. Consensus: process and desirability 3.1 Timing of delivery 3.2 Language and perceived negativity 3.3 Effective communication - language and accessibility 3.4 Goal setting and stress 3.5 Societal expectation and internalised pressure 3.6 Prioritisation: focus on birth and guilt avoidance 3.7 Gaps and inconsistencies: communication, education and support Theme 1: Acceptability of the card 1.1 Encouragement and relevance Professionals expressed general satisfaction with the card, pointing out its relevance, inclusion of appropriate images, and focus on key breastfeeding issues in a clear and concise manner. I think they really hit the nail on the head (Professional, 6) And the mentioning of the 'fourth trimester', I think, is just really good…(Professional, 2) Healthcare professionals praised the card for its encouraging content. They highlighted its inclusivity, flexibility, and positive tone. Yes. I love “your new family is now a team”, because I think that’s very inclusive of whoever else is within the home, I think that’s lovely (professional, 5) Additionally, some professionals noted that the planning (volitional) aspect of the card has the potential to empower mothers by shaping their behaviours and perceptions around breastfeeding through goal setting and action planning. ..... but actually breastfeed for longer, that could be really positive for them to see, oh, this is what I had planned but here I am now two months later or whatever and I’m still doing it, so I suppose that’s quite a positive thing as well maybe for your behaviour (Professional, 6) 1.2 Effect on breastfeeding experience: Positive enhancement All mothers felt a card could have a positive impact on the breastfeeding experience and highlighted several key areas. Provision of positive emotional support could be enhanced by offering reassurance, reducing anxiety by addressing common concerns, and normalising the challenge associated with breastfeeding. But before having the baby, I said, I’ll just try and breastfeed, if I can do, that will be great, if I can’t, it’s fine. But actually when you’re in that moment, you’re almost stubborn and determined, it’s so emotional. So I really thought at that point, I need to breastfeed. I refused the formula. So to have this just as a little pick me up, like, oh, it is going to be difficult, it confirms that, but I’ll get through it, would have been great (Mother, 4) Mothers also perceived the card would encourage them to set realistic expectations of mental and physical demands of breastfeeding by offering valuable ‘insights’ prior to birth and potentially facilitate meaningful conversations around practical preparations. Normalising breastfeeding challenges was also helpful. So to have a wee bit of an insight that it is going to be difficult, but these are the numbers to find help or advice, that might have been useful (Mother, 2) I would have quite liked to have actually had more difficulties signposted before I went into my breastfeeding journey, because I thought that I was the only one having these problems and everybody else was getting on fine, and just wasn’t the case at all. So for me, I would have really liked to have had those (Mother 5) Additionally, the reminder function of the card was a tool for setting and reinforcing breastfeeding goals and motivations. This prompt was designed to help mothers establish their intentions and allow them to reflect on these intentions. Discussions around this prompt were extensive, with several differing opinions being raised, challenged and then evolving during the focus group. Prompts regarding the length of time they planned to breastfeed were seen as useful, although it is worth noting that some mothers thought it was important to prioritise achieving the ‘benefits’ rather than strict adherence to specific time goals. The format of the card is a really good idea because obviously the thing you write on it [ ie breastfeeding goal] is really great, to remind you that this thing exists (Mother, 4) So you could then give that card before someone gives birth and they’re able to look and say, well, I was thinking about breastfeeding and I’m definitely going to breastfeed now because I see these benefits (Mother, 5) Theme 2: Content and design 2.1 Clarity of card content: Visual communication and realistic experience Mothers recognized the proposed card size was 'different' from normal and stood out from other support resources. However, they said that that aspects of visual communication can be improved to make it more clear and appealing to mothers. Suggestions include avoiding being text-heavy and using ‘pictograms’ to present the content in an easy-to-understand manner and engaging users with ‘jazzy’, ‘eye-catching’ designs and ‘catchy’ titles. But also just having it that size, because all the stuff in my antenatal notes was sheets of paper, and just having it in a way that you can [have it] with you, that’s really good (Mother, 4) It looks quite…I hesitate to say, academic, it’s big blocks of text with not a lot of pictures …(Mother,1) I don’t know whether calling it solutions to your common breastfeeding concerns, there’s quite a lot of words and text there. It’s almost like an SOS or like a breastfeeding survival kit, or whatever it is you want to brand it, something a bit more… catchy (Mother, 3) Mothers acknowledged that the card content addresses the realistic challenges mothers usually face with breastfeeding. However, they noted it is crucial to clearly communicate the potential for pain and discomfort, along with the validation of struggles and milestones to ensure it captures realistic breastfeeding experiences. It says breastfeeding is uncomfortable or painful, and then it says, there are all these things you can do. But my frustration at the start was, they were saying, oh well, he’s attached fine and that looks good. And I’m like, it’s absolutely excruciatingly sore. But everyone was saying, well, everything looks fine, it’s normal. And I was like, well, if I’m not doing anything wrong and this is all right and this is how it feels, like what on earth is going on? (Mother, 1) 2.2 Desired information: Engaging design and promoting positive experience Some mothers expressed the desire for an engaging card design. They suggested using a dual-sided card that presents both the benefits of breastfeeding and information related to challenges and support. Additionally, they recommended including personalized elements or interactive engagement. I really like the picture thing, but maybe if you could almost circle the most important for you, like the number one thing. But maybe have to have like the due date on so that you write your due date, so it’s like personal to you, something like that (Mother, 2) The inclusion of further information to promote positive breastfeeding experiences was highlighted by majority of mothers as desirable content. This includes some recommendations to positively frame the breastfeeding experience, such as incorporating a positive ‘mantra’ to acknowledge mother’s effort and reassure them they are doing well. So you’ve listed these concerns here. Is there any way that you would…you could almost put like a positive kind of mantra linked to each concern. So others bonding with the baby: today my partner did this to bond with the baby, like underneath it, so then you can look back and think, actually, I am doing things right. (Mother, 6) Other recommendations focused on the idea of shared responsibility, aiming to foster a supportive environment that actively encourages the partners and family members to contribute to the breastfeeding journey. It highlighted breastfeeding should not be the mother’s sole responsibility. I feel others have a massive role to play in the breastfeeding experience as well. So even maybe something there about, even though your partner or your family isn’t actually feeding the baby… My partner was running about mad bringing me water and passing me the remote control (Mother, 1) Additionally, supporting an individual’s feeding choice was identified as significant in promoting a positive breastfeeding experience. Mothers felt the excessive focus on exclusive breastfeeding could create pressure and guilt. In light of this, they stressed the importance of providing information for a more inclusive and understanding approach to infant feeding. If you can’t or don’t want to breastfeed. It’s like that should be respected and you shouldn’t be made to feel worse (Mother, 1) The mothers highlighted the relevance of the card content and how benefits, realistic advice and signposting to support would be desirable to inform and prepare for breastfeeding. The interactive utility of the card was also praised although there was discussion regarding how to engage with women’s intentions to breastfeed. The card had a space for the user to write their intended duration of breastfeeding, however mothers raised concerns this may subsequently trigger feelings of guilt if the desired timescale was not achieved. Alternative suggestions such as including incremental attainment of breastfeeding benefits or circling the reasons they wanted to breastfeed were proposed. When we were talking about this incremental idea of attainment, that if I had seen, in three days, if you want to give up, you’ve given your baby colostrum, and actually this is the benefit of colostrum, then I think I would have felt less pressured. Because I would have thought, well, if in three days I can’t do this anymore and the nipple trauma is too bad, then I’ve done this amazing thing (Mother, 5) 2.3 Potential misinformation or harm: Some professionals expressed concern about specific messages on the card. In particular, the advice to 'treat existing nipple trauma with barrier cream' was inappropriate as it suggested a quick fix rather than addressing the underlying issue and seeking help. Professionals' discussions suggested alternative phrasing or broadening the discussion about nipple trauma to clarify its 'discomfort' but not 'damage' nature. I’m just not sure if that’s…something doesn’t quite fit right because what we’d want to do is it not to be occurring anyway. I know it’s happened and I know we’ve talked there about attachment and positioning. I don’t know, there’s just something…it’s almost like making it a quick fix whereas actually we need to resolve the issue (Professional, 3) Some mothers expressed that the information stated on the card did not align with the actual support they received during the hospital stay and interaction with the healthcare professionals. This discrepancy suggests challenges for practice and the need for improved alignment within standard antenatal care. Mothers felt the card could validate feelings of frustration and disappointment when expectations did not align with the actual service provided. I did do research, but, for example, the milk thing was a massive concern for me and I even had family saying, oh, are you sure she’s got enough milk? She was absolutely fine. But if I’d known beforehand, it’s fine, she’s got regular nappies, that would have really helped (Mother, 4) Some mothers noted the concern that the card could potentially hinder breastfeeding experiences. In particular, mothers who have not yet had a baby may perceive breastfeeding as negative and unfavourable if the card was received in isolation. Additionally, mothers experiencing difficulties during their time breastfeeding could view the information on the card as exacerbating their negative emotions and guilt. But kind of getting this just itself, especially if you’ve not had the baby yet, and I don’t think I had much of an idea of anything until he was actually here…(Mother, 2) So it’s really hard, because I think, yeah, you probably do need it at the start so you know that you need that information about why you should breastfeed, and then, if it’s a straightforward and smooth journey, great. But I think if it’s a bit of a bumpy ride, like we had, that would probably have served just to make me feel worse and more guilty, I think (Mother, 6) 2.4 Validation-mechanism of action Professionals were generally positive about the content and felt the card could provide validation to mothers. That includes but is not limited to acknowledging individuals' 'unique' experiences, normalising the physical discomfort sensation associated with breastfeeding and validating the accomplishments and milestones of breastfeeding, even just the 'first three days'. Saying your breastfeeding experience with your baby is unique because what they do is they all share information and mums talk and then, oh, why is their baby sleeping overnight for six hours and mine isn’t? And there’s no answer to that (Professional, 7) It depends on the timing as well, you know? I think we don’t always help women saying that breastfeeding should be 100 per cent comfortable if you’re doing it right… I mean, you’re sticking in a super-sensitive part of your body to be ferociously sucking several times a day, it’s going to smart (Professional, 2) Yes, I talked about this, reasons to breastfeed and when they say you’ve done the first breastfeed, well done, you have done this, did you manage to breastfeed your baby for the first three days, excellent, this is what you’ve done, because sometimes that kind of exclusively breastfeed for six months can feel like such a mountain for women to…(Professional, 2) Theme 3: Consensus: process and desirability This theme collates the discussions from both professionals and mothers and presents a consensus regarding key elements of the process and desirability of delivering the intentions card and essential components of card content and its mechanisms. 3.1 Timing of delivery Timing of dissemination of the card raised two essential factors for consideration. First, at what point of pregnancy and breastfeeding would the card most benefit the mother to support breastfeeding decision making? Second, at what time point would the card most suit the antenatal care pathway in terms of its interaction with other support and education and the midwives’ workload? Both factors raised points to consider in both the utility and relevance of the card and feasibility of the intervention. Based on established standardised care plans, healthcare professionals identified the 32 weeks of pregnancy appointment as a feasible time to distribute the card , because this allows additional time for questions and discussion. It was noted that the 36-week appointment may not be suitable due to birth preferences discussions occurring at the same time. The consensus among professionals was that delivering the card at 36 weeks would be too late. So, at 32 we are just doing contraception, chat about everything else, so I think 32 weeks would probably be a bit better for us to give the card out… if I was giving them out there will be questions from my women, I can assure you about that. So, I think 32 weeks gives them that little bit longer…(Professional, 2) Healthcare professionals identified further opportunities to engage mothers with the card by being involved with integrated care. The health visiting services provide a home visit during the antenatal period which could facilitate a breastfeeding conversation and opportunities to follow up with mothers to ensure they received the card. These suggestions indicate the potential acceptability of the card within existing healthcare services. I know you’re saying it’s for midwifery, but we do an antenatal contact for health visiting service between 32 to 34 weeks in the home, it’s really relaxed, we talk about birth plan… and I always bring up feeding and I say, what are your thoughts on feeding, you know? So that’s, like, a really good opportunity, it’s quite relaxed (Professional, 1) In contrast, mothers held varying views regarding the timing of delivering the card and the underlying reasons. Some mothers suggest 34-36 weeks of pregnancy would be the optimal timing of distributing the card, as it allows them to make informed decisions about breastfeeding while avoiding the risk of receiving the card too early, potentially forgetting when the needs arise. I suppose it’s whether you get this at 33 weeks and you sort of put it away in a drawer somewhere (Mother, 1) Others considered the value of having the card and support from healthcare professionals after childbirth, as it allows practical assistance with breastfeeding when the newborn and midwife are both present. Additionally, some mothers emphasised the need for receiving guidance and assistance precisely when they are facing breastfeeding challenges as ‘SOS’ support rather than beforehand, but others disagree as it may trigger more stress. …instead of giving it before you’ve had the baby, in one of the appointments that you have with your midwife in the days after you’ve given birth, so when they come to your house. Just because then… I mean, for me, that’s when the most conversations about breastfeeding happen and she was there, the baby was there, we worked on it, having that, for when she (midwife) went away, then it would have probably been more use to me (Mother, 6) And maybe if the midwives had a stock of them, because I can see that you might be going into a house and you might have said, I’ve got that card but I’ve no idea what I’ve done with it...Give you another one if they see that you’re maybe struggling and could be doing with it. (Mother, 1) However for some mothers the thought of receiving the card as support during challenging breastfeeding times was inappropriate. If someone had then handed me that card when I was crying every time I was pumping formula into her, it wouldn’t have worked that well at all (Mother,6). Overall, mothers appreciated support for breastfeeding regardless of when the card is provided. Since 2017 the Scottish Government has provided a 'baby box' for all new babies, which includes infant care supplies and information on breastfeeding and baby care [22]. Some mothers highlighted the opportunity to deliver the card along with the baby box, as it aligns with their active exploration of baby-related items. Because we got our baby box, we were super-excited to receive it, we went through everything. And so actually if that card was really bright and really exciting and that was in a baby box, we would probably have been, oh, what’s this, what’s this one about? And we’d probably have read it when we were looking (Mother, 6) Whereas professionals also reflected some considerations of when and how to engage in discussions about breastfeeding. In particular, they mentioned deliberately choosing a relaxed setting can help facilitate an open breastfeeding conversation, and the relevance of channelling these conversations to those who had previous breastfeeding difficulties. These discussions highlighted key aspects of the card’s utility. The card could be versatile in its use to either support breastfeeding preparations in the antenatal period, or provide support during challenging breastfeeding periods. Additionally, the card could enhance antenatal feeding conversations with midwifery and health visiting staff. 3.2 Language and perceived negativity Discussions in both focus groups raised issues with specific language, tone and perceptions, specifically, how the card evoked feelings and behaviours in mothers. However, there was general consensus from the mothers about the value of realistic and honest information which would appropriately prepare women to breastfeed. A fine line between presenting realistic expectations of breastfeeding versus cautious, considered expressions to avoid negative perceptions was difficult to navigate. Some professionals noted the specific language presented on the card could lead to feelings of guilt or anxiety among mothers. They suggested revising the wording to be less ‘demanding’, ‘negative’ and more inclusive, for example, including terms such as ‘varied’ or ‘emerging patterns’ instead of ‘erratic’ to describe newborn behaviour. I’m not saying erratic is a bad word but it might be a bit daunting, like, oh, when am I going to get to sleep? How many times in a day will this baby feed? I don’t know if there’s a way to say it differently (Professional, 7) 3.3 Effective Communication: Language and accessibility Professionals highlighted the importance of considering the needs and preferences of the recipients in effectively communicating breastfeeding related messages to provide a sense of empowerment, including being mindful of the language used and ensuring that information is accessible and relevant to the diverse audience. I think a lot of it is to do with the language that’s used around breastfeeding, so what I hear is I would like to or I’m going to try to breastfeed… but we’ve got some formula in just in case at home, and so I think it’s giving them that sort of power to say, actually, I want to do this (Professional,7) Accessibility of the card was discussed by both professionals and mothers, specifically regarding the readability, legibility and utility. Health professionals were mainly concerned about the potential language and literacy barriers that could impact the accessibility of the card but also the small size of text which could be difficult for some to engage with. Mothers expressed a similar concern regarding the accessibility of the card’s information, considering factors such as language translation, data usage and providing information to individuals without access to smartphones. 3.4 Goal setting and stress Some professionals and mothers questioned the use of the planning message: ‘I intend to breastfeed for..’ which may lead to potential pressure and negative feelings by focusing on duration of breastfeeding rather than the benefits of any breastmilk. I’m also thinking when I have my baby, I intend to breastfeed for…I was just worried that could be like a trigger thing and a pressure thing for some women? I think maybe the reasons why I intend to breastfeed, I think, is a nicer way to put it…because sometimes that kind of exclusively breastfeed for six months can feel like such a mountain for women (Professional, 2) Furthermore, one mother highlighted inclusion of the assumption of breastfeeding intention which may create stress and disappointment if mothers cannot or choose not to breastfeed . if you’ve got something that says, when I have my baby, I intend to breastfeed for…I think you’re making an assumption that all women do intend to breastfeed or want to breastfeed. Because there could be women for whom the idea of breastfeeding is just not something that they want to do, and then having that could… There is this thing about lots of guilt…And if in your mind, for whatever reason you don’t want to, I think reading that, you might think, oh, I actually don’t intend to breastfeed and you’re not giving me any option to say (Mother, 1) In addition, the professionals expressed a desire to include further information which could support easy solutions to breastfeeding challenges (e.g. ‘CHINS’ (Close in, Head free, Inline, Nose to nipple, Sustainable). Would you put.. if you gave them the CHINS, because that’s a solution in a way, isn’t it (Professional, 6) Professionals also stressed the importance of prompting mothers to seek assistance from health professionals when needed, extending this to include health visitor and family nurse. I think even starting off the box saying ask your midwife/health visitor/family nurse to observe feeding I think is really the first thing you want to happen (Professional, 1) Whereas one mother expressed a desire for trustworthy information from reliable and official sources like ‘NHS’ regarding challenging topics such as ‘nipple trauma’ or ‘latching’ skills. The mother emphasized the need for easy accessibility through links, preferably in the form of short videos. To have support that’s from the NHS as well, like official support, because once you fall down a rabbit hole with breastfeeding, and I’m sure you guys have all found this, there’s so much inaccurate information out there (Mother, 5) 3.5 Societal expectation and internalised pressure Both professionals and mothers addressed the challenge and complexity of motherhood, including internalised multiple societal pressures and breastfeeding expectations placed on mothers, which could lead to self-doubt and sense of personal failure which could be reinforced by the card. I think in the breastfeeding world I think there’s this kind of six month really hard target that I think some women find that difficult and because that’s already kind of out there in the world and women kind of internalise it…there’s that external pressure, isn’t there? That six months of exclusive breastfeeding which is then going to affect how women feel about this (Professional, 4) In addition, both professionals and mothers highlighted comparisons with others within social circles or support groups which can exacerbate feelings of pressure and self-doubt. I thought that I was the only one having these problems and everybody else was getting on fine...(Mother, 5) 3.6 Prioritisation: focus on birth and guilt avoidance Both professionals and mothers highlighted how the emphasis during pregnancy is often placed on the birth itself, and there may be a lack of awareness or preparation about the difficulties and pressures that can come with breastfeeding once the baby is born. … most of the time we’re just sort of zoned in on the birth, you know, that’s the main event …(Professional, 1) So maybe that’s why it is so difficult, because there’s nothing on how difficult it’s going to be. You just think, get through the birth and then you’ll be fine. But you’ve got so much going on with the body and then the feeds are such a pressure (Mother, 2) In addition, some professionals prioritise guilt avoidance when deciding whether to distribute breastfeeding materials to expectant mothers who may not wish to breastfeed, aimed at preventing mothers from feeling guilty about their choices later. However, there was a lack of consensus among professionals, as this practice may result in some mothers not being fully informed about breastfeeding benefits and therefore not able to make informed decisions or change their mind about feeding method. ...interestingly they choose not to give out the Off to a Good Start book to women who don’t want to breastfeed so that they’re not made to feel guilty is the thinking behind it... I’ve been told to do it just because we don’t want to make women feel guilty is what I’m told (Professional, 4) 3.7 Gaps and inconsistencies: Communication, Education and Support Both professionals and mothers emphasised existing gaps in communication, education and service delivery in supporting breastfeeding mothers. Mothers focused more on the gap in support, particularly in terms of practical assistance from healthcare professionals. They noted disappointment, confusion and frustration when the expectation of service didn't align with reality. I felt like I did everything I possibly could to get things going off on the right start, but the support I got in the hospital wasn’t adequate. All things that might be happening for you that you can resolve yourself, but the reality was, if I had more support in the hospital. I mean, he wasn’t fed for like 12 hours after he was born because nobody came to help us or support us, and that got us off on the worst possible foot at the worst possible start. (Mother, 2) Professionals focused more specifically on gaps in breastfeeding education, such as the role of skin-to-skin contact, realistic expectations about breastfeeding discomfort, and the reasons behind the need for a frequent, adequate milk supply. I think we don’t always help women saying that breastfeeding should be 100 per cent comfortable if you’re doing it right. Yes, sure, you know? I think that we’re setting up…(Professional, 2) Like I always talk about breastfeeding as a lifestyle…It’s actually trying to prepare them for the fact that actually the baby’s going to feed really frequently because it’s got a small tummy, because it needs to be close to you, because of milk supply (Professional, 7) Professionals highlighted issues related to the lack of standardization in antenatal practice, which includes providing information and facilitating educational opportunities. Specifically in practice, some geographical teams did not provide health visitor home visits during the antenatal period. Professionals also expressed general frustration regarding current antenatal practices, particularly regarding the gap in providing informed choice to expectant mothers, and the concern that some practices may be passed down without critical evaluation. Yes, a lot of it is just information that’s been passed from one midwife to another and they’ve been doing stuff as well, and then they just think that’s what everybody does, so they just continue doing what everybody does (Professional, 5) Summary of Findings: Amending the card These findings generally supported the rationale for development of the content of the intentions card and suggestions for practical design to support dissemination through routine antenatal care. Table 2 summarises the main recommendations for adaptation to card design and content from both mothers and health professionals. Table 2: Summary of Recommendations for Card Content and Redesign Theme Suggested Amendment Signposting to services Link to local information (support groups) Freephone (rather than paid) helpline Links to NHS information (videos) Content Realistic and inclusive, validate mothers' experiences Personalised information (eg due date) Focus on positive experiences, Shared breastfeeding responsibility Incremental approach (praise short-term success) Prompts to seek help from professionals Design Avoid being 'academic' and text-heavy Easy readability Use positive language Use pictograms Be eye-catching Credit card size, dual sided Accessibility for diverse audience Delivery Professionals: around 32 weeks to allow time for Qs During home visits; relaxed setting Mothers: 34-36 weeks (to avoid forgetting) Multiple deliveries of card: Also use postnatally for additional support With Baby Box (NHS Scotland) The card was subsequently redesigned using the feedback above, to be evaluated in routine antenatal care in future research. Discussion The overall response to the potential introduction of a prompt card delivered in the later stages of pregnancy aiming to support women in establishing and maintaining breastfeeding was very positive. Both health professionals and women with experience of breastfeeding described the need for multiple, accessible sources of support for women, and this approach was viewed as an additional helpful and pragmatic tool to provide this support. The relevance and potential impact on women's experience of breastfeeding was seen as positive. If the amendments suggested (Table 2) were adopted, it appears that use of a theory based breastfeeding planning card, using both motivational and volitional approaches may have potential to add value to existing services and enhance the support offered in the perinatal period for women who wish to breastfeed. There is evidence elsewhere that the motivational approach based on the HAPA model can influence intention to exclusively breastfeed [23] and that volitional and planning interventions can improve health behaviours [24, 25]. Despite some reservations, participants generally felt that stating intentions in advance would be helpful to support breastfeeding behaviours. Content and Design: There was general consensus on most topics included in the card content and design within and between the groups, although discussions cautioned against stigmatising women who either did not wish to breastfeed or chose not to continue beyond the early stages, and highlighted the need for realistic and pragmatic information. There appeared to be several potential mechanisms of action in delivery of the card, including validation, realism and guilt. Two possible barriers to use of the card included increasing mother’s guilt and causing distress due to a mismatch between the reality of infant feeding challenges and availability of support, which may have discouraged continued breastfeeding. Validation The breastfeeding card had potential to evoke validation for mothers through offering support, addressing common concerns, normalizing difficulties with breastfeeding and potentially reducing anxiety. This suggests validation of experiences should be a key aspect of breastfeeding support, as highlighted in a recent review of self-conscious emotions and breastfeeding whereby mechanisms validating women's breastfeeding experiences reduced shame, guilt and support establishment of a maternal identity [26]. Realism Provision of positive but realistic preparation advice for mothers was advocated strongly by both focus groups, reiterating messages from breastfeeding mothers in other studies calling for realistic advice [27, 28,29]. The card was seen as an opportunity to provide information to prepare new parents for the 'realities' of breastfeeding experiences which was seen as being helpful and preferable to an over-optimistic view. Pre-partum knowledge is likely to have a significant positive impact on breastfeeding confidence [30], nevertheless there may also be potential for excessive realism to cause anticipatory anxiety and lower self-efficacy (particularly in first-time parents) and negatively influence behavioural decision making around initiating or maintaining breastfeeding. Fostering 'realistic optimism' may be the most psychologically supportive route in the transition to motherhood [31]. Guilt A potentially negative mechanism of action discussed was instilling feelings of guilt through setting a goal for the intended duration of breastfeeding. While this supported women’s volition, failure to meet the stated duration could potentially backfire if goals were not achieved. Guilt is often associated with early motherhood and experiences of breastfeeding [26,28, 32]. In addition to placing the responsibility on themselves, mothers have also reported feeling guilty of failing to breastfeed due to perceptions of negative judgement by health care professionals [26] and guilt is associated with poorer maternal wellbeing [33]. Evoking guilt would be contrary to the ethos of this intervention, so addressing negative language and inconsistent information is therefore a key priority in adapting the content of the intentions card to provide realistic but encouraging and confidence-building information. Consensus in Content, Process and Desirability Different priorities for mothers, based on their experiences of need for information and support, and health professionals based on the demands of their work role, were reflected in different views on the optimal delivery of the card. Consistent care, support and encouragement from health professionals and others with lived experience of breastfeeding is crucial to developing confidence and positive experiences. Whilst the intentions card provided practical tips to support preparation for breastfeeding, the experiences reported by our focus group participants suggests a lack of consistency in provision of support across NHS clinics and health boards. Providing consistent information is important, but how this information is delivered in practice affects how it is received and acted upon. The role of health professionals, including nurses, midwives and community nurses is crucial [34]. Information provision should be underpinned by training in breastfeeding and patient-centred communication methods for healthcare staff involved with mothers in the perinatal period [35,36]. A topic of much debate in current midwifery practice, education and wider society is the use of non-stigmatising language and terminology which is inclusive, and non-discriminatory [37]. Within maternity services, specific terms such as “mother” and “woman” are debated as we acknowledge maternity services provide care for people who do not identify with these nouns. This conversation has evolved to include the use of the term “breastfeeding” which to some is discriminatory [37]. Discussions surrounding the use of specific terms such as “breastfeeding” or “chest-feeding” were raised during the focus group discussions. However, it was also a priority of the research team to ensure the intervention and feasibility study upheld the principles of the global Unicef and WHO “Baby Friendly Initiative” standards [17], since the study was within a UK “Baby Friendly Accredited” practice area. Professionals tended to use the term ‘breastfeeding’ in the context of baby-friendly promotion. Others acknowledged the evolving nature of terminology to represent and include various groups of people given the potential implications of using different terms to describe the act of breastfeeding, while also being mindful not to marginalize the majority of those who identify with traditional terminology. Importantly health professionals highlighted the need to be sensitive to individuals based on their own experiences. It is interesting that awareness of the potential for guilt and stigma experienced by women who choose not to breastfeed was identified as a barrier for supporting breastfeeding using the planning card (and other materials) by some professionals. Although understandable, this assumption may inadvertently disadvantage those who are ambivalent or change their mind about feeding method in the perinatal period. Limitations A limitation of this small-scale study was lack of representation of diverse populations. All those who took part were all mothers overtly identified as women. We did not purposively seek to recruit participants from marginalized populations and different ethnic/cultural groups were not represented. For future research and development of interventions which could be provided to all parents, it would be advantageous to ensure diversity within the participant population. Additionally the study was carried out in one WHO/Unicef Accredited UK 'Baby Friendly' health board area - so may not be representative of the views of women and professionals elsewhere. Conclusion This study sought to provide insight to the delivery of a breastfeeding planning card as part of a pilot RCT. It aimed to inform the feasibility and acceptability to support longer and more satisfying breastfeeding experiences, and of embedding the planning card within standard antenatal care. When updated to include relevant, realistic advice, and avoid language which may provoke feelings of guilt and anxiety it could be useful in many health service settings. Practicalities of embedding the card within standard antenatal care were considered and optimal timing was agreed to be the 32-week antenatal midwife appointment. However, the card showed promise for additional opportunities to be used by health visitors during antenatal and postnatal home visits, hospital postnatal care and even included in the Baby Box, issued by the Scottish Government to all expectant families. Abbreviations HAPA – Health Action Process Approach IRAS – Integrated Research Application System NHS – National Health Service (UK) PIS – Participant Information Sheet UNICEF – United Nations Children’s Fund WHO – World Health Organisation Declarations Ethics approval and consent to participate The study protocol was approved by University of Stirling Ethics Committee (NICR 2022 8214 6595). UK health service IRAS ethics application was approved by NHS Black Country Research Ethics Committee and by ACCORD NHS Lothian Research and Development office [17-8-22, 22/WM/0168] The Participant Information Sheet (PIS) was sent to all participants via email upon expressing interest in the study. An information pack containing the PIS and consent form was distributed to participants on the day of the focus groups and signed consent forms were collected by a researcher. Consent for publication : Not applicable Availability of data and materials : The datasets generated during this study are not publicly available as this may compromise individual privacy. Competing interests : the Authors declare they have no competing interests. Funding: This study was funded by the Chief Scientist Office for Scotland, Grant Reference HIPS/21/49 Authors' contributions : A A-A contributed to study design, data collection and analysis and drafting of manuscript. 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Breastfeeding in primiparous women – expectations and reality: a prospective questionnaire survey. BMC Preg Childbirth. 2023; 23: 654. https://doi.org/10.1186/s12884-023-05971-1 Callahan Churchill A, Davis CG. Realistic orientation and the transition to motherhood. motherhood. J Soc Clin Psychol. 2010; 29, 1: 39–67. DOI 10.1521/jscp.2010.29.1.39. Harrison M, Hepworth J, Brodribb W. Navigating motherhood and maternal transitional infant feeding: Learnings for health professionals. Appetite. 2018; 121: 228-236, ISSN 0195-6663, https://doi.org/10.1016/j.appet.2017.11.095. Fallon VM, Harrold JA, Chisholm A. The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed-methods systematic review. Matern Child Nutr. 2019; 15:e12778. https://doi.org/10.1111/mcn.12778 Couto C, Prata AP, Souto SP, Machado J, Viana CR. Nurse and midwife interventions to protect, promote and support breastfeeding: An umbrella review. 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Supplementary Files Appendix1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 31 Jul, 2025 Editor invited by journal 27 Jun, 2025 Editor assigned by journal 26 Jun, 2025 Submission checks completed at journal 26 Jun, 2025 First submitted to journal 26 Jun, 2025 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-6985799","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494644044,"identity":"283c2037-22ca-4186-af2f-3480b88daf79","order_by":0,"name":"Alix Aitken-Arbuckle","email":"","orcid":"","institution":"Edinburgh Napier University","correspondingAuthor":false,"prefix":"","firstName":"Alix","middleName":"","lastName":"Aitken-Arbuckle","suffix":""},{"id":494644045,"identity":"674a101e-0fca-4f1a-9da4-2f1665ec7a1d","order_by":1,"name":"David Comerford","email":"","orcid":"","institution":"University of Stirling","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Comerford","suffix":""},{"id":494644046,"identity":"90e52de7-b066-4932-9736-9064a4dc919c","order_by":2,"name":"Susannah Boardman","email":"","orcid":"","institution":"University of Stirling","correspondingAuthor":false,"prefix":"","firstName":"Susannah","middleName":"","lastName":"Boardman","suffix":""},{"id":494644047,"identity":"030de18f-f10b-495e-b652-77b5186ea954","order_by":3,"name":"Ailin Chen","email":"","orcid":"","institution":"University of Stirling","correspondingAuthor":false,"prefix":"","firstName":"Ailin","middleName":"","lastName":"Chen","suffix":""},{"id":494644048,"identity":"107aacd2-38af-41f3-8f99-2f1489f1ada2","order_by":4,"name":"Vivien Swanson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIie2RMUvDQBTH33FwWe7omqB+h0ggU/C+Sg6hU/ATdCgEnkuka4PgZ3CSbl44iEu0a6GL7hkSXHQomGIFFa52dLjf9N7w4/8efwCH4x8SGgD9bU8A6G70D1TGwP9U9M/dAP8abUpwyU91vwAZPjyarl8spfTEM7xNQJVTi5LzsCobULfNxTgom7UqqBeSogZ1bUvJWWoEQhrrLKYC1ymnDEBMQd1YlBEdlA2CjJdt9CrwSW4VstmrUG0IArlbZeGRQE2KQaHbFNthbFCqK/TV/aqNgxLPVWEYmOPaj2zvs1GVd++YyGCWRV2PZ9Kb1eSlnSQnc22J+eRXB9reisPhcDgO4QNbKFQ3TxxaswAAAABJRU5ErkJggg==","orcid":"","institution":"University of Stirling","correspondingAuthor":true,"prefix":"","firstName":"Vivien","middleName":"","lastName":"Swanson","suffix":""}],"badges":[],"createdAt":"2025-06-26 18:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6985799/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6985799/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88691594,"identity":"a049b34d-c90b-43ae-acdb-f05ea269850d","added_by":"auto","created_at":"2025-08-09 14:47:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":183216,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBreastfeeding Planning Card Used in Focus Groups\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6985799/v1/2cc73d4a86a287b710a5f247.png"},{"id":88692121,"identity":"6ee306db-989e-4bfe-a6bb-b11bf839dd1c","added_by":"auto","created_at":"2025-08-09 14:55:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1322107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6985799/v1/5ad69317-15d9-47bd-85a8-01c8fa2228a4.pdf"},{"id":88691423,"identity":"035ee8e6-21b3-4287-9795-585e3141d48f","added_by":"auto","created_at":"2025-08-09 14:39:40","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15648,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6985799/v1/d57794416b093924077e330c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Would a Planning Card Help New Mothers Achieve their Breastfeeding Goals? Evidence from Focus Groups of Mothers and Health Professionals","fulltext":[{"header":"Background","content":"\u003cp\u003ePromoting good health in early years is one of 6 public health priorities identified by the Scottish Government [1]. Nutrition is key. The World Health Organization recommends that infants are exclusively breastfed for the first six months of life [2]. Infants who are breastfed enjoy better health and developmental outcomes than formula-fed infants [3]. These benefits increase with breastfeeding duration and exclusivity. Additionally, breastfeeding has substantial health benefits for mothers, associated with reduced incidence of breast and ovarian cancers, osteoporosis and diabetes. It is also beneficial for uterine involution, weight loss, natural contraception [4,5] and\u0026nbsp;has psychosocial benefits including reduced stress and postnatal depression and increased postnatal maternal well-being [6]. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eScotland has low rates of breastfeeding initiation and duration by international standards; just 68% of newborns are breastfed, dropping to 49% at 6-8 weeks postpartum [7]. In 2018, the Scottish Government identified rates of breastfeeding drop-off in the postpartum period as a particular concern and its \u0026apos;Diet and Healthy Weight Delivery Plan\u0026apos; states a commitment to reduce drop-off in breastfeeding rates at six to eight weeks after birth by 10% by 2025 [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis current study builds on previous work using a theory-based approach to reduce breastfeeding drop-off. Behavioural science theories help us to understand and improve health promoting behaviours such as breastfeeding by specifying key influences and determinants and their relationship with behaviours. Both initiating and maintaining behaviours are important for good health, and different factors might be at play in these stages of behaviour change [9]. \u0026nbsp;Health Action Process Approach (HAPA) theory distinguishes between two stages that determine whether a behaviour is likely to be maintained: (a) a motivational stage where people form an intention to act, and (b) a volitional stage where people form and enact concrete plans to carry out the intended behaviour [10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePublic health campaigns in Scotland have generally addressed the motivational stage by providing information on the benefits to mother and baby of breastfeeding. For example, NHS Scotland has published posters (\u0026ldquo;Breastmilk Benefits\u0026rdquo; and \u0026ldquo;Breast milk versus Formula\u0026rdquo;) and disseminated booklets (\u0026ldquo;Ready Steady Baby\u0026rdquo; and \u0026ldquo;Off to a Good Start\u0026rdquo; [11]). Also, the Scottish Government has sought to address social barriers to breastfeeding via the Breastfeeding Act, 2005, setting out a legal right to breastfeed in public places. Available evidence suggests that these public health campaigns have proven successful at promoting breastfeeding intentions and increasing initiation [12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhere the Scottish public health community has been less successful is in the \u0026apos;enactment\u0026apos; or volitional stage of the HAPA model. Many women start breastfeeding but quit soon afterwards [12,13,14]. A recent study sought to address that gap. Researchers delivered a breastfeeding planning card to women who were at least 36 weeks pregnant. The planning card reduced drop-off from breastfeeding four-fold[15]. \u0026nbsp; This planning card intervention could have substantial effects on breastfeeding maintenance if scaled-up across the Scottish population and would have applicability in other contexts where breastfeeding drop-off is a problem. The majority of drop-off in Scotland occurs in the first two-weeks post-partum and 86% of mothers report that they would have liked to have breastfed for longer [12]. These statistics imply that new mothers face practical difficulties implementing their intentions to breastfeed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne mechanism through which the card might have its effects is by enhancing breastfeeding self-efficacy, a key component of the HAPA model related to putting behavioural intentions into action [16]. To the extent that breastfeeding is a \u0026apos;natural\u0026apos; human behaviour, new mothers may expect it to come naturally i.e. effortlessly and without complications. That expectation could lead mothers to conclude that any difficulties they experience are non-normal. The card enhances self-efficacy by informing mothers that it is normal to experience some difficulties when breastfeeding and so reassures that there is nothing \u0026lsquo;wrong\u0026rsquo; with them or their baby. Additionally, the card provides \u0026apos;troubleshooting\u0026apos; tips (coping planning) which may give mothers a sense of increased mastery and control over the breastfeeding process supporting enactment and maintenance of breastfeeding behaviours [16].\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was developed to determine the feasibility of delivering the planning card previously used as a research tool, as part of standard antenatal care in line with NHS and WHO/Unicef (2014) Baby Friendly Initiative recommendations [17]. These standards for maternity, neonatal and community care include promotion of breastfeeding. We first elicited opinions from a Co-Production Research Team (see below) to devise the questions used in focus groups. These questions focused on desirability, design and content. Two focus groups were held, one made up of midwives, health visitors and infant feeding coordinators, the other comprising breastfeeding women who had recently given birth. This study presents a thematic analysis of findings from these focus groups, exploring perceptions of the barriers, facilitators and benefits of antenatal delivery and use of the planning card.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy Aims\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1. To assess the perceived suitability of the design and content of a planning card to support breastfeeding, including motivational (breastfeeding planning intentions) and volitional (\u0026apos;if-then\u0026apos; coping planning) aspects of the card content.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. To assess whether midwives and mothers consider it feasible, acceptable and desirable for the planning card to be delivered during standard antenatal care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. To determine the most efficient protocol for delivery of the card i.e. how can delivery of the card complement existing midwifery practice?\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eThis qualitative study was part of a wider feasibility study and designed to maximise study quality and impact [18]. It included two focus groups with practitioners and those with lived experience of breastfeeding. The focus group discussions were semi-structured using tailored topic guides for mothers and midwives [\u003cem\u003eAppendix 1]\u003c/em\u003e prompting discussion of specific topics related to acceptability and feasibility of delivering the breastfeeding planning card in routine antenatal care.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in accordance with principles of the International Conference on Harmonisation Tripartite Guideline for Good Clinical Practice (1995)[19]. These focus on trial quality. The study protocol was approved by University of Stirling Ethics Committee (NICR \u0026nbsp;2022 8214 6595). The UK health service IRAS ethics application was reviewed by NHS Black Country Research Ethics Committee and by ACCORD NHS Lothian Research and Development office [17-8-22, 22/WM/0168]\u003c/p\u003e\n\u003ch3\u003eSettings and participants\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in a large health board in central Scotland with a birth rate of approximately 9,000 per year. Focus groups were held in a community health and social care partnership site where community services are offered.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA Co-Production Research Team\u003c/em\u003e was established during study development to support aspects of study design and recruitment. This comprised five individuals: two practising midwives who had worked in the health board and one infant feeding practitioner, one midwife and one student midwife from a different health board. \u0026nbsp;The team met online over several months prior to data collection to aid development of the intervention and again following the focus groups to support analysis of findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAn Advisory Group\u003c/em\u003e comprising two senior academics - health psychologists experienced in behavioural research methods also oversaw the conduct of the research, meeting the research team three times throughout the duration of the project to advise on design, data collection, analysis and dissemination.\u003c/p\u003e\n\u003ch4\u003eFocus Group Participants\u003c/h4\u003e\n\u003cp\u003e\u003cem\u003eRecruitment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants for both groups were recruited using purposive sampling techniques. The health professionals were recruited through email advertisement to their NHS email accounts via their clinical managers. These asked any interested parties to contact the research team directly to participate in the focus groups.\u003c/p\u003e\n\u003cp\u003eWomen with lived experience of breastfeeding were recruited via posters displayed in local infant feeding support groups. Interested parties were asked to contact the research team directly if they wanted to participate. The Participant Information Sheet (PIS) was sent to all participants via email upon expressing interest in the study, allowing them sufficient time to review it before making a decision about participation. An information pack containing the PIS and consent form was distributed to participants on the day of the focus groups and signed consent forms were collected by a researcher.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFocus Groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBoth focus groups were conducted on the one day in January 2023. The first was with health professionals and the second was with women with current or very recent lived experience of breastfeeding. Seven health professionals were recruited, two midwives, one student midwife, one health visitor and three infant feeding specialists. \u0026nbsp;The healthcare professionals\u0026apos; focus group lasted 64 minutes and took place during lunch time at a local health and social care outpatient base.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSix women attended the focus group which lasted 65 minutes and was held in the afternoon in the same outpatient base. \u0026nbsp;Participants were all white-Scottish, two had more than one child. Following the focus group, a \u0026pound;20 voucher was emailed to participants to compensate for their time and travel costs.\u003c/p\u003e\n\u003cp\u003eFocus group interview schedules \u003cem\u003e[Appendix 1]\u003c/em\u003e were developed collaboratively by the co-researcher group and advisory team and investigated the acceptability, desirability, design and content of the breastfeeding planning card. Both groups were conducted by experienced facilitators and midwives in the research team. They were audio-recorded and transcribed verbatim. During the focus groups, participants were introduced to the study by explaining the rationale based on previous work. Professionals were also asked how the card content \u0026apos;fits\u0026apos; with existing information provision and practice, informed by the WHO/UNICEF Baby Friendly Initiative, and any potential harms from its use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlanning Card\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were then given a copy of the Breastfeeding Planning Card to review. This was presented in hard-copy as shown in Figure 1. \u0026nbsp;It was proposed that the final version would be \u0026apos;credit card\u0026apos; sized, and this was discussed in the groups. The QR code linked to local breastfeeding support services.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eAnalysis was conducted using NVivo [20] and Microsoft software. \u0026nbsp;Transcripts were analysed simultaneously. \u0026nbsp;The Framework Analysis Approach was applied to the transcripts to draw out key themes and discussion [21]. A framework of categories was developed in agreement with the research team, focusing on the key areas of interest outlined in the focus group interview schedule and research objectives. Subsequently, the data were assigned to the framework for initial coding. This framework was adapted to ensure new codes or themes were included. Initial coding was conducted by a midwife researcher using an inductive approach, and the codebooks were reviewed by the research team to refine themes and conduct further coding. The analysis involved cross-referencing codes, selecting illustrative quotes, and facilitating comparisons between themes. The Framework Analysis provided a structure and enabled exploration and comparison of similarities and differences in perspectives between healthcare professionals and mothers. As part of the analysis process the research team discussed any fundamental problems regarding perceived feasibility and acceptability of the card which may affect use in practice. These and identified mechanisms of action were noted and considered during the analysis [18].\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe findings highlighted aspects of the perceived acceptability, desirability, design and content of the breastfeeding planning card. Health professionals and women with breastfeeding lived experiences discussed these aspects in detail, reflecting on the content and utility of the card and the process of embedding the card within wider antenatal routine care. Potential weaknesses in the card design were identified. Discussions identified some key mechanisms of action which confirmed a priori theories of how the card could support positive breastfeeding behaviours. The following themes and subthemes were identified as shown in Table 1. \u0026nbsp;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Summary of Focus Group Themes and Sub-themes\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSub-theme\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Acceptability of the card\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e1.1 Encouragement and relevance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e1.2 Effect on breastfeeding experience: Positive enhancement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Content and design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e2.1 Clarity of card content: visual communication and realistic experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e2.2 Desired information: Engaging design and promoting positive experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e2.3 Potential misinformation or harm\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e2.4 Validation - mechanism of action\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Consensus: process and desirability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.1 Timing of delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.2 Language and perceived negativity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.3 Effective communication - language and accessibility\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.4 Goal setting and stress\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.5 Societal expectation and internalised pressure\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.6 \u0026nbsp;Prioritisation: focus on birth and guilt avoidance\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e3.7 Gaps and inconsistencies: communication, education and support\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cem\u003eTheme 1: Acceptability of the card\u003c/em\u003e\u003c/h3\u003e\n\u003ch4\u003e1.1 Encouragement and relevance\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eProfessionals expressed general satisfaction with the card, pointing out its relevance, inclusion of appropriate images, and focus on key breastfeeding issues in a clear and concise manner.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think they really hit the nail on the head (Professional, 6)\u003c/p\u003e\n\u003cp\u003eAnd the mentioning of the \u0026apos;fourth trimester\u0026apos;, I think, is just really good\u0026hellip;(Professional, 2)\u003c/p\u003e\n\u003cp\u003eHealthcare professionals praised the card for its encouraging content. They highlighted its inclusivity, flexibility, and positive tone.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes. I love \u0026ldquo;your new family is now a team\u0026rdquo;, because I think that\u0026rsquo;s very inclusive of whoever else is within the home, I think that\u0026rsquo;s lovely (professional, 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, some professionals noted that the planning (volitional) aspect of the card has the potential to empower mothers by shaping their behaviours and perceptions around breastfeeding through goal setting and action planning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e..... but actually breastfeed for longer, that could be really positive for them to see, oh, this is what I had planned but here I am now two months later or whatever and I\u0026rsquo;m still doing it, so I suppose that\u0026rsquo;s quite a positive thing as well maybe for your behaviour (Professional, 6)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003e1.2 Effect on breastfeeding experience: Positive enhancement\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eAll mothers felt a card could have a positive impact on the breastfeeding experience and highlighted several key areas. Provision of positive emotional support could be enhanced by offering reassurance, reducing anxiety by addressing common concerns, and normalising the challenge associated with breastfeeding. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBut before having the baby, I said, I\u0026rsquo;ll just try and breastfeed, if I can do, that will be great, if I can\u0026rsquo;t, it\u0026rsquo;s fine. But actually when you\u0026rsquo;re in that moment, you\u0026rsquo;re almost stubborn and determined, it\u0026rsquo;s so emotional. So I really thought at that point, I need to breastfeed. I refused the formula. So to have this just as a little pick me up, like, oh, it is going to be difficult, it confirms that, but I\u0026rsquo;ll get through it, would have been great (Mother, 4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMothers also perceived the card would encourage them to set realistic expectations of mental and physical demands of breastfeeding by offering valuable \u0026lsquo;insights\u0026rsquo; prior to birth and potentially facilitate meaningful conversations around practical preparations. Normalising breastfeeding challenges was also helpful.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo to have a wee bit of an insight that it is going to be difficult, but these are the numbers to find help or advice, that might have been useful (Mother, 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI would have quite liked to have actually had more difficulties signposted before I went into my breastfeeding journey, because I thought that I was the only one having these problems and everybody else was getting on fine, and just wasn\u0026rsquo;t the case at all. So for me, I would have really liked to have had those (Mother 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, the reminder function of the card was a tool for setting and reinforcing breastfeeding goals and motivations. This prompt was designed to help mothers establish their intentions and allow them to reflect on these intentions. Discussions around this prompt were extensive, with several differing opinions being raised, challenged and then evolving during the focus group. Prompts regarding the length of time they planned to breastfeed were seen as useful, although it is worth noting that some mothers thought it was important to prioritise achieving the \u0026lsquo;benefits\u0026rsquo; rather than strict adherence to specific time goals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe format of the card is a really good idea because obviously the thing you write on it\u003c/em\u003e[ ie breastfeeding goal] \u003cem\u003e\u0026nbsp;is really great, to remind you that this thing exists (Mother, 4)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo you could then give that card before someone gives birth and they\u0026rsquo;re able to look and say, well, I was thinking about breastfeeding and I\u0026rsquo;m definitely going to breastfeed now because I see these benefits (Mother, 5)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eTheme 2: Content and design\u0026nbsp;\u003c/em\u003e\u003c/h3\u003e\n\u003ch4\u003e2.1 Clarity of card content: Visual communication and realistic experience\u003c/h4\u003e\n\u003cp\u003eMothers recognized the proposed card size was \u0026apos;different\u0026apos; from normal \u0026nbsp;and stood out from other support resources. However, they said that that aspects of visual communication can be improved to make it more clear and appealing to mothers. Suggestions include avoiding being text-heavy and using \u0026lsquo;pictograms\u0026rsquo; to present the content in an easy-to-understand manner and engaging users with \u0026lsquo;jazzy\u0026rsquo;, \u0026lsquo;eye-catching\u0026rsquo; designs and \u0026lsquo;catchy\u0026rsquo; titles.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBut also just having it that size, because all the stuff in my antenatal notes was sheets of paper, and just having it in a way that you can\u0026nbsp;\u003c/em\u003e[have it]\u003cem\u003e\u0026nbsp;with you, that\u0026rsquo;s really good (Mother, 4)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt looks quite\u0026hellip;I hesitate to say, academic, it\u0026rsquo;s big blocks of text with not a lot of pictures \u0026hellip;(Mother,1)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI don\u0026rsquo;t know whether calling it solutions to your common breastfeeding concerns, there\u0026rsquo;s quite a lot of words and text there. It\u0026rsquo;s almost like an SOS or like a breastfeeding survival kit, or whatever it is you want to brand it, something a bit more\u0026hellip; catchy (Mother, 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMothers acknowledged that the card content addresses the realistic challenges mothers usually face with breastfeeding. However, they noted it is crucial to clearly communicate the potential for pain and discomfort, along with the validation of struggles and milestones to ensure it captures realistic breastfeeding experiences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt says breastfeeding is uncomfortable or painful, and then it says, there are all these things you can do. But my frustration at the start was, they were saying, oh well, he\u0026rsquo;s attached fine and that looks good. And I\u0026rsquo;m like, it\u0026rsquo;s absolutely excruciatingly sore. But everyone was saying, well, everything looks fine, it\u0026rsquo;s normal. And I was like, well, if I\u0026rsquo;m not doing anything wrong and this is all right and this is how it feels, like what on earth is going on? (Mother, 1)\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003e2.2 Desired information: Engaging design and promoting positive experience\u003c/h4\u003e\n\u003cp\u003eSome mothers expressed the desire for an engaging card design. They suggested using a dual-sided card that presents both the benefits of breastfeeding and information related to challenges and support. Additionally, they recommended including personalized elements or interactive engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI really like the picture thing, but maybe if you could almost circle the most important for you, like the number one thing. But maybe have to have like the due date on so that you write your due date, so it\u0026rsquo;s like personal to you, something like that (Mother, 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe inclusion of further information to promote positive breastfeeding experiences was highlighted by majority of mothers as desirable content. This includes some recommendations to positively frame the breastfeeding experience, such as incorporating a positive \u0026lsquo;mantra\u0026rsquo; to acknowledge mother\u0026rsquo;s effort and reassure them they are doing well.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo you\u0026rsquo;ve listed these concerns here. Is there any way that you would\u0026hellip;you could almost put like a positive kind of mantra linked to each concern. So others bonding with the baby: today my partner did this to bond with the baby, like underneath it, so then you can look back and think, actually, I am doing things right. (Mother, 6)\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther recommendations focused on the idea of shared responsibility, aiming to foster a supportive environment that actively encourages the partners and family members to contribute to the breastfeeding journey. It highlighted breastfeeding should not be the mother\u0026rsquo;s sole responsibility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI feel others have a massive role to play in the breastfeeding experience as well. So even maybe something there about, even though your partner or your family isn\u0026rsquo;t actually feeding the baby\u0026hellip; My partner was running about mad bringing me water and passing me the remote control (Mother, 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, supporting an individual\u0026rsquo;s feeding choice was identified as significant in promoting a positive breastfeeding experience. Mothers felt the excessive focus on exclusive breastfeeding could create pressure and guilt. In light of this, they stressed the importance of providing information for a more inclusive and understanding approach to infant feeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf you can\u0026rsquo;t or don\u0026rsquo;t want to breastfeed. It\u0026rsquo;s like that should be respected and you shouldn\u0026rsquo;t be made to feel worse (Mother, 1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mothers highlighted the relevance of the card content and how benefits, realistic advice and signposting to support would be desirable to inform and prepare for breastfeeding. The interactive utility of the card was also praised although there was discussion regarding how to engage with women\u0026rsquo;s intentions to breastfeed. The card had a space for the user to write their intended duration of breastfeeding, however mothers raised concerns this may subsequently trigger feelings of guilt if the desired timescale was not achieved. \u0026nbsp;Alternative suggestions such as including incremental attainment of breastfeeding benefits or circling the reasons they wanted to breastfeed were proposed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen we were talking about this incremental idea of attainment, that if I had seen, in three days, if you want to give up, you\u0026rsquo;ve given your baby colostrum, and actually this is the benefit of colostrum, then I think I would have felt less pressured. Because I would have thought, well, if in three days I can\u0026rsquo;t do this anymore and the nipple trauma is too bad, then I\u0026rsquo;ve done this amazing thing\u003c/em\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003cem\u003e(Mother, 5)\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch4\u003e2.3 Potential misinformation or harm: \u0026nbsp;\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eSome professionals expressed concern about specific messages on the card. In particular, the advice to \u0026apos;treat existing nipple trauma with barrier cream\u0026apos; was inappropriate as it suggested a quick fix rather than addressing the underlying issue and seeking help. Professionals\u0026apos; discussions suggested alternative phrasing or broadening the discussion about nipple trauma to clarify its \u0026apos;discomfort\u0026apos; but not \u0026apos;damage\u0026apos; nature. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;m just not sure if that\u0026rsquo;s\u0026hellip;something doesn\u0026rsquo;t quite fit right because what we\u0026rsquo;d want to do is it not to be occurring anyway. I know it\u0026rsquo;s happened and I know we\u0026rsquo;ve talked there about attachment and positioning. I don\u0026rsquo;t know, there\u0026rsquo;s just something\u0026hellip;it\u0026rsquo;s almost like making it a quick fix whereas actually we need to resolve the issue (Professional, 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome mothers expressed that the information stated on the card did not align with the actual support they received during the hospital stay and interaction with the healthcare professionals. This discrepancy suggests challenges for practice and the need for improved alignment within standard antenatal care. Mothers felt the card could validate feelings of frustration and disappointment when expectations did not align with the actual service provided.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI did do research, but, for example, the milk thing was a massive concern for me and I even had family saying, oh, are you sure she\u0026rsquo;s got enough milk? She was absolutely fine. But if I\u0026rsquo;d known beforehand, it\u0026rsquo;s fine, she\u0026rsquo;s got regular nappies, that would have really helped (Mother, 4)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome mothers noted the concern that the card could potentially hinder breastfeeding experiences. In particular, \u0026nbsp;mothers who have not yet had a baby may perceive breastfeeding as negative and unfavourable if the card was received in isolation. Additionally, mothers experiencing difficulties during their time breastfeeding could view the information on the card as exacerbating their negative emotions and guilt.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBut kind of getting this just itself, especially if you\u0026rsquo;ve not had the baby yet, and I don\u0026rsquo;t think I had much of an idea of anything until he was actually here\u0026hellip;(Mother, 2)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo it\u0026rsquo;s really hard, because I think, yeah, you probably do need it at the start so you know that you need that information about why you should breastfeed, and then, if it\u0026rsquo;s a straightforward and smooth journey, great. But I think if it\u0026rsquo;s a bit of a bumpy ride, like we had, that would probably have served just to make me feel worse and more guilty, I think (Mother, 6)\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003e2.4 Validation-mechanism of action\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eProfessionals were generally positive about the content and felt the card could provide validation to mothers. That includes but is not limited to acknowledging individuals\u0026apos; \u0026apos;unique\u0026apos; experiences, normalising the physical discomfort sensation associated with breastfeeding and validating the accomplishments and milestones of breastfeeding, even just the \u0026apos;first three days\u0026apos;.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSaying your breastfeeding experience with your baby is unique because what they do is they all share information and mums talk and then, oh, why is their baby sleeping overnight for six hours and mine isn\u0026rsquo;t? And there\u0026rsquo;s no answer to that (Professional, 7)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt depends on the timing as well, you know? I think we don\u0026rsquo;t always help women saying that breastfeeding should be 100 per cent comfortable if you\u0026rsquo;re doing it right\u0026hellip; I mean, you\u0026rsquo;re sticking in a super-sensitive part of your body to be ferociously sucking several times a day, it\u0026rsquo;s going to smart (Professional, 2)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes, I talked about this, reasons to breastfeed and when they say you\u0026rsquo;ve done the first breastfeed, well done, you have done this, did you manage to breastfeed your baby for the first three days, excellent, this is what you\u0026rsquo;ve done, because sometimes that kind of exclusively breastfeed for six months can feel like such a mountain for women to\u0026hellip;(Professional, 2)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eTheme 3: Consensus: process and desirability\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThis theme collates the discussions from both professionals and mothers and presents a consensus regarding key elements of the process and desirability of delivering the intentions card and essential components of card content and its mechanisms.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e3.1 Timing of delivery\u003c/h4\u003e\n\u003cp\u003eTiming of dissemination of the card raised two essential factors for consideration. First, at what point of pregnancy and breastfeeding would the card most benefit the mother to support breastfeeding decision making? Second, at what time point would the card most suit the antenatal care pathway in terms of its interaction with other support and education and the midwives\u0026rsquo; workload? Both factors raised points to consider in both the utility and relevance of the card and feasibility of the intervention. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on established standardised care plans, healthcare professionals identified the 32 weeks of pregnancy appointment\u0026nbsp;as a feasible time to distribute the card\u003cem\u003e,\u0026nbsp;\u003c/em\u003ebecause this allows additional time for questions and discussion. It was noted that the 36-week appointment may not be suitable due to birth preferences discussions occurring at the same time. The consensus among professionals was that delivering the card at 36 weeks would be too late.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo, at 32 we are just doing contraception, chat about everything else, so I think 32 weeks would probably be a bit better for us to give the card out\u0026hellip; if I was giving them out there will be questions from my women, I can assure you about that. So, I think 32 weeks gives them that little bit longer\u0026hellip;(Professional, 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals identified further opportunities to engage mothers with the card by being involved with integrated care. The health visiting services provide a home visit during the antenatal period which could facilitate a breastfeeding conversation and opportunities to follow up with mothers to ensure they received the card. These suggestions indicate the potential acceptability of the card within existing healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI know you\u0026rsquo;re saying it\u0026rsquo;s for midwifery, but we do an antenatal contact for health visiting service between 32 to 34 weeks in the home, it\u0026rsquo;s really relaxed, we talk about birth plan\u0026hellip; and I always bring up feeding and I say, what are your thoughts on feeding, you know? So that\u0026rsquo;s, like, a really good opportunity, it\u0026rsquo;s quite relaxed (Professional, 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, mothers held varying views regarding the timing of delivering the card and the underlying reasons. Some mothers suggest 34-36 weeks of pregnancy would be the optimal timing of distributing the card, as it allows them to make informed decisions about breastfeeding while avoiding the risk of receiving the card too early, potentially forgetting when the needs arise. \u0026nbsp;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI suppose it\u0026rsquo;s whether you get this at 33 weeks and you sort of put it away in a drawer somewhere (Mother, 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOthers considered the value of having the card and support from healthcare professionals after childbirth, as it allows practical assistance with breastfeeding when the newborn and midwife are both present. Additionally, some mothers emphasised the need for receiving guidance and assistance precisely when they are facing breastfeeding challenges as \u0026lsquo;SOS\u0026rsquo; support rather than beforehand, but others disagree as it may trigger more stress.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;instead of giving it before you\u0026rsquo;ve had the baby, in one of the appointments that you have with your midwife in the days after you\u0026rsquo;ve given birth, so when they come to your house. Just because then\u0026hellip; I mean, for me, that\u0026rsquo;s when the most conversations about breastfeeding happen and she was there, the baby was there, we worked on it, having that, for when she (midwife) went away, then it would have probably been more use to me (Mother, 6)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnd maybe if the midwives had a stock of them, because I can see that you might be going into a house and you might have said, I\u0026rsquo;ve got that card but I\u0026rsquo;ve no idea what I\u0026rsquo;ve done with it...Give you another one if they see that you\u0026rsquo;re maybe struggling and could be doing with it. (Mother, 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever for some mothers the thought of receiving the card as support during challenging breastfeeding times was inappropriate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf someone had then handed me that card when I was crying every time I was pumping formula into her, it wouldn\u0026rsquo;t have worked that well at all (Mother,6).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall, mothers appreciated support for breastfeeding regardless of when the card is provided. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince 2017 the Scottish Government has provided a \u0026apos;baby box\u0026apos; for all new babies, which includes infant care supplies and information on breastfeeding and baby care [22]. \u0026nbsp; Some mothers highlighted the opportunity to deliver the card along with the baby box, as it aligns with their active exploration of baby-related items.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBecause we got our baby box, we were super-excited to receive it, we went through everything. And so actually if that card was really bright and really exciting and that was in a baby box, we would probably have been, oh, what\u0026rsquo;s this, what\u0026rsquo;s this one about? And we\u0026rsquo;d probably have read it when we were looking (Mother, 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhereas professionals also reflected some considerations of when and how to engage in discussions about breastfeeding. In particular, they mentioned deliberately choosing a relaxed setting can help facilitate an open breastfeeding conversation, and the relevance of channelling these conversations to those who had previous breastfeeding difficulties.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese discussions highlighted key aspects of the card\u0026rsquo;s utility. The card could be versatile in its use to either support breastfeeding preparations in the antenatal period, or provide support during challenging breastfeeding periods. \u0026nbsp;Additionally, the card could enhance antenatal feeding conversations with midwifery and health visiting staff.\u003c/p\u003e\n\u003ch4\u003e3.2 Language and perceived negativity\u003c/h4\u003e\n\u003cp\u003eDiscussions in both focus groups raised issues with specific language, tone and perceptions, specifically, how the card evoked feelings and behaviours in mothers. However, there was general consensus from the mothers about the value of realistic and honest information which would appropriately prepare women to breastfeed. A fine line between presenting realistic expectations of breastfeeding versus cautious, considered expressions to avoid negative perceptions was difficult to navigate. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome professionals noted the specific language presented on the card could lead to feelings of guilt or anxiety among mothers. They suggested revising the wording to be less \u0026lsquo;demanding\u0026rsquo;, \u0026lsquo;negative\u0026rsquo; and more inclusive, for example, including terms such as \u0026lsquo;varied\u0026rsquo; or \u0026lsquo;emerging patterns\u0026rsquo; instead of \u0026lsquo;erratic\u0026rsquo; to describe newborn behaviour.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;m not saying erratic is a bad word but it might be a bit daunting, like, oh, when am I going to get to sleep? How many times in a day will this baby feed? I don\u0026rsquo;t know if there\u0026rsquo;s a way to say it differently (Professional, 7)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e3.3 Effective Communication:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eLanguage and accessibility\u003c/h4\u003e\n\u003cp\u003eProfessionals highlighted the importance of considering the needs and preferences of the recipients in effectively communicating breastfeeding related messages to provide a sense of empowerment, including being mindful of the language used and ensuring that information is accessible and relevant to the diverse audience. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think a lot of it is to do with the language that\u0026rsquo;s used around breastfeeding, so what I hear is I would like to or I\u0026rsquo;m going to try to breastfeed\u0026hellip; but we\u0026rsquo;ve got some formula in just in case at home, and so I think it\u0026rsquo;s giving them that sort of power to say, actually, I want to do this (Professional,7)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccessibility of the card was discussed by both professionals and mothers, specifically regarding the readability, legibility and utility. Health professionals were mainly concerned about the potential language and literacy barriers that could impact the accessibility of the card but also the small size of text which could be difficult for some to engage with.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMothers expressed a similar concern regarding the accessibility of the card\u0026rsquo;s information, considering factors such as language translation, data usage and providing information to individuals without access to smartphones. \u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e3.4 Goal setting and stress\u003c/h4\u003e\n\u003cp\u003eSome professionals and mothers questioned the use of the planning message: \u0026lsquo;I intend to breastfeed for..\u0026rsquo; which may lead to potential pressure and negative feelings by focusing on duration of breastfeeding rather than the benefits of any breastmilk.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;m also thinking when I have my baby, I intend to breastfeed for\u0026hellip;I was just worried that could be like a trigger thing and a pressure thing for some women? I think maybe the reasons why I intend to breastfeed, I think, is a nicer way to put it\u0026hellip;because sometimes that kind of exclusively breastfeed for six months can feel like such a mountain for women (Professional, 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, one mother highlighted inclusion of the assumption of breastfeeding intention which may create stress and disappointment if mothers cannot or choose not to breastfeed\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eif you\u0026rsquo;ve got something that says, when I have my baby, I intend to breastfeed for\u0026hellip;I think you\u0026rsquo;re making an assumption that all women do intend to breastfeed or want to breastfeed. Because there could be women for whom the idea of breastfeeding is just not something that they want to do, and then having that could\u0026hellip; There is this thing about lots of guilt\u0026hellip;And if in your mind, for whatever reason you don\u0026rsquo;t want to, I think reading that, you might think, oh, I actually don\u0026rsquo;t intend to breastfeed and you\u0026rsquo;re not giving me any option to say (Mother, 1)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition, the professionals expressed a desire to include further information which could support easy solutions to breastfeeding challenges (e.g. \u0026lsquo;CHINS\u0026rsquo; (Close in, Head free, Inline, Nose to nipple, Sustainable).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWould you put.. if you gave them the CHINS, because that\u0026rsquo;s a solution in a way, isn\u0026rsquo;t it (Professional, 6)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessionals also stressed the importance of prompting mothers to seek assistance from health professionals when needed, extending this to include health visitor and family nurse.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think even starting off the box saying ask your midwife/health visitor/family nurse to observe feeding I think is really the first thing you want to happen (Professional, 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhereas one mother expressed a desire for trustworthy information from reliable and official sources like \u0026lsquo;NHS\u0026rsquo; regarding challenging topics such as \u0026lsquo;nipple trauma\u0026rsquo; or \u0026lsquo;latching\u0026rsquo; skills. \u0026nbsp;The mother emphasized the need for easy accessibility through links, preferably in the form of short videos.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTo have support that\u0026rsquo;s from the NHS as well, like official support, because once you fall down a rabbit hole with breastfeeding, and I\u0026rsquo;m sure you guys have all found this, there\u0026rsquo;s so much inaccurate information out there (Mother, 5)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e3.5 Societal expectation and internalised pressure\u003c/h4\u003e\n\u003cp\u003eBoth professionals and mothers addressed the challenge and complexity of motherhood, including internalised multiple societal pressures and breastfeeding expectations placed on mothers, which could lead to self-doubt and sense of personal failure which could be reinforced by the card.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think in the breastfeeding world I think there\u0026rsquo;s this kind of six month really hard target that I think some women find that difficult and because that\u0026rsquo;s already kind of out there in the world and women kind of internalise it\u0026hellip;there\u0026rsquo;s that external pressure, isn\u0026rsquo;t there? That six months of exclusive breastfeeding which is then going to affect how women feel about this (Professional, 4)\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, both professionals and mothers highlighted comparisons with others within social circles or support groups which can exacerbate feelings of pressure and self-doubt.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI thought that I was the only one having these problems and everybody else was getting on fine...(Mother, 5)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e3.6 Prioritisation: focus on birth and guilt avoidance\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eBoth professionals and mothers highlighted how the emphasis during pregnancy is often placed on the birth itself, and there may be a lack of awareness or preparation about the difficulties and pressures that can come with breastfeeding once the baby is born.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip; most of the time we\u0026rsquo;re just sort of zoned in on the birth, you know, that\u0026rsquo;s the main event \u0026hellip;(Professional, 1) \u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo maybe that\u0026rsquo;s why it is so difficult, because there\u0026rsquo;s nothing on how difficult it\u0026rsquo;s going to be. You just think, get through the birth and then you\u0026rsquo;ll be fine. But you\u0026rsquo;ve got so much going on with the body and then the feeds are such a pressure (Mother, 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition, some professionals prioritise guilt avoidance when deciding whether to distribute breastfeeding materials to expectant mothers who may not wish to breastfeed, aimed at preventing mothers from feeling guilty about their choices later. However, there was a lack of consensus among professionals, as this practice may result in some mothers not being fully informed about breastfeeding benefits and therefore not able to make informed decisions or change their mind about feeding method. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e...interestingly they choose not to give out the Off to a Good Start book to women who don\u0026rsquo;t want to breastfeed so that they\u0026rsquo;re not made to feel guilty is the thinking behind it... I\u0026rsquo;ve been told to do it just because we don\u0026rsquo;t want to make women feel guilty is what I\u0026rsquo;m told (Professional, 4)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e3.7 Gaps and inconsistencies: Communication, Education and Support\u003c/h4\u003e\n\u003cp\u003eBoth professionals and mothers emphasised existing gaps in communication, education and service delivery in supporting breastfeeding mothers. Mothers focused more on the gap in support, particularly in terms of practical assistance from healthcare professionals. They noted disappointment, confusion and frustration when the expectation of service didn\u0026apos;t align with reality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI felt like I did everything I possibly could to get things going off on the right start, but the support I got in the hospital wasn\u0026rsquo;t adequate. All things that might be happening for you that you can resolve yourself, but the reality was, if I had more support in the hospital. I mean, he wasn\u0026rsquo;t fed for like 12 hours after he was born because nobody came to help us or support us, and that got us off on the worst possible foot at the worst possible start. (Mother, 2) \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eProfessionals focused more specifically on gaps in breastfeeding education, such as the role of skin-to-skin contact, realistic expectations about breastfeeding discomfort, and the reasons behind the need for a frequent, adequate milk supply.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think we don\u0026rsquo;t always help women saying that breastfeeding should be 100 per cent comfortable if you\u0026rsquo;re doing it right. Yes, sure, you know? I think that we\u0026rsquo;re setting up\u0026hellip;(Professional, 2)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLike I always talk about breastfeeding as a lifestyle\u0026hellip;It\u0026rsquo;s actually trying to prepare them for the fact that actually the baby\u0026rsquo;s going to feed really frequently because it\u0026rsquo;s got a small tummy, because it needs to be close to you, because of milk supply (Professional, 7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eProfessionals highlighted issues related to the lack of standardization in antenatal practice, which includes providing information and facilitating educational opportunities. Specifically in practice, some geographical teams did not provide health visitor home visits during the antenatal period. Professionals also expressed general frustration regarding current antenatal practices, particularly regarding the gap in providing informed choice to expectant mothers, and the concern that some practices may be passed down without critical evaluation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes, a lot of it is just information that\u0026rsquo;s been passed from one midwife to another and they\u0026rsquo;ve been doing stuff as well, and then they just think that\u0026rsquo;s what everybody does, so they just continue doing what everybody does (Professional, 5)\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSummary of Findings: Amending the card\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese findings generally supported the rationale for development of the content of the intentions card and suggestions for practical design to support dissemination through routine antenatal care. Table 2 summarises the main recommendations for adaptation to card design and content from both mothers and health professionals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: Summary of Recommendations for Card Content and Redesign\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSuggested Amendment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignposting to services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eLink to local information (support groups)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFreephone (rather than paid) helpline\u003c/p\u003e\n \u003cp\u003eLinks to NHS information (videos)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eRealistic and inclusive, validate mothers\u0026apos; experiences\u003c/p\u003e\n \u003cp\u003ePersonalised information (eg due date)\u003c/p\u003e\n \u003cp\u003eFocus on positive experiences,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eShared breastfeeding responsibility\u003c/p\u003e\n \u003cp\u003eIncremental approach (praise short-term success)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrompts to seek help from professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eAvoid being \u0026apos;academic\u0026apos; and text-heavy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEasy readability\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUse positive language\u003c/p\u003e\n \u003cp\u003eUse pictograms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBe eye-catching\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCredit card size, dual sided\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAccessibility for diverse audience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelivery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eProfessionals:\u003c/em\u003e around 32 weeks to allow time for Qs\u003c/p\u003e\n \u003cp\u003eDuring home visits; relaxed setting\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMothers:\u003c/em\u003e 34-36 weeks (to avoid forgetting)\u003c/p\u003e\n \u003cp\u003eMultiple deliveries of card: Also use postnatally for additional support\u003c/p\u003e\n \u003cp\u003eWith Baby Box (NHS Scotland)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe card was subsequently redesigned using the feedback above, to be evaluated in routine antenatal care in future research.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overall response to the potential introduction of a prompt card delivered in the later stages of pregnancy aiming to support women in establishing and maintaining breastfeeding was very positive. \u0026nbsp;Both health professionals and women with experience of breastfeeding described the need for multiple, accessible sources of support for women, and this approach was viewed as an additional helpful and pragmatic tool to provide this support. The relevance and potential impact on women\u0026apos;s experience of breastfeeding was seen as positive. \u0026nbsp;If the amendments suggested (Table 2) were adopted, it appears that use of a theory based breastfeeding planning card, using both motivational and volitional approaches may have potential to add value to existing services and enhance the support offered in the perinatal period for women who wish to breastfeed. \u0026nbsp; There is evidence elsewhere that the motivational approach based on the HAPA model can influence intention to exclusively breastfeed [23] and that volitional and planning interventions can improve health behaviours [24, 25]. Despite some reservations, participants generally felt that stating intentions in advance would be helpful to support breastfeeding behaviours.\u003c/p\u003e\n\u003cp\u003eContent and Design: There was general consensus on most topics included in the card content and design within and between the groups, although discussions cautioned against stigmatising women who either did not wish to breastfeed or chose not to continue beyond the early stages, and highlighted the need for realistic and pragmatic information. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere appeared to be several potential mechanisms of action in delivery of the card, including validation, realism and guilt. Two possible barriers to use of the card included increasing mother\u0026rsquo;s guilt and causing distress due to a mismatch between the reality of infant feeding challenges and availability of support, which may have discouraged continued breastfeeding.\u003c/p\u003e\n\u003cp\u003eValidation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe breastfeeding card had potential to evoke validation for mothers through offering support, addressing common concerns, normalizing difficulties with breastfeeding and potentially reducing anxiety. This suggests validation of experiences should be a key aspect of breastfeeding support, as highlighted in a recent review of self-conscious emotions and breastfeeding whereby mechanisms validating women\u0026apos;s breastfeeding experiences reduced shame, guilt and support establishment of a maternal identity [26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRealism\u003c/p\u003e\n\u003cp\u003eProvision of positive but realistic preparation advice for mothers was advocated strongly by both focus groups, reiterating messages from breastfeeding mothers in other studies calling for realistic advice [27, 28,29]. The card was seen as an opportunity to provide information to prepare new parents for the \u0026apos;realities\u0026apos; of breastfeeding experiences which was seen as being helpful and preferable to an over-optimistic view. \u0026nbsp;Pre-partum knowledge is likely to have a significant positive impact on breastfeeding confidence [30], nevertheless there may also be potential for excessive realism to cause anticipatory anxiety and lower self-efficacy (particularly in first-time parents) and negatively influence behavioural decision making around initiating or maintaining breastfeeding. Fostering \u0026apos;realistic optimism\u0026apos; may be the most psychologically supportive route in the transition to motherhood [31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGuilt\u003c/p\u003e\n\u003cp\u003eA potentially negative mechanism of action discussed was instilling feelings of guilt through setting a goal for the intended duration of breastfeeding. While this supported women\u0026rsquo;s volition, failure to meet the stated duration could potentially backfire if goals were not achieved. Guilt is often associated with early motherhood and experiences of breastfeeding [26,28, 32]. In addition to placing the responsibility on themselves, mothers have also reported feeling guilty of failing to breastfeed due to perceptions of negative judgement by health care professionals [26] and guilt is associated with poorer maternal wellbeing [33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvoking guilt would be contrary to the ethos of this intervention, so addressing negative language and inconsistent information is therefore a key priority in adapting the content of the intentions card to provide realistic but encouraging and confidence-building information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsensus in Content, Process and Desirability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDifferent priorities for mothers, based on their experiences of need for information and support, and health professionals based on the demands of their work role, were reflected in different views on the optimal delivery of the card. \u0026nbsp;Consistent care, support\u003cem\u003e\u0026nbsp;\u003c/em\u003eand encouragement from health professionals and\u003cem\u003e\u0026nbsp;\u003c/em\u003eothers with lived experience of breastfeeding is crucial to developing confidence and positive experiences. Whilst the intentions card provided practical tips to support preparation for breastfeeding, the experiences reported by our focus group participants suggests a lack of consistency in provision of support across NHS clinics and health boards. \u0026nbsp;Providing consistent information is important, but how this information is delivered in practice affects how it is received and acted upon. The role of health professionals, including nurses, midwives and community nurses is crucial [34]. \u0026nbsp;Information provision should be underpinned by training in breastfeeding and patient-centred communication methods for healthcare staff involved with mothers in the perinatal period [35,36].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA topic of much debate in current midwifery practice, education and wider society is the use of non-stigmatising language and terminology which is inclusive, and non-discriminatory [37]. Within maternity services, specific terms such as \u0026ldquo;mother\u0026rdquo; and \u0026ldquo;woman\u0026rdquo; are debated as we acknowledge maternity services provide care for people who do not identify with these nouns. This conversation has evolved to include the use of the term \u0026ldquo;breastfeeding\u0026rdquo; which to some is discriminatory [37]. Discussions surrounding the use of specific terms such as \u0026ldquo;breastfeeding\u0026rdquo; or \u0026ldquo;chest-feeding\u0026rdquo; were raised during the focus group discussions. However, it was also a priority of the research team to ensure the intervention and feasibility study upheld the principles of the global Unicef and WHO \u0026ldquo;Baby Friendly Initiative\u0026rdquo; standards [17], since the study was within a UK \u0026ldquo;Baby Friendly Accredited\u0026rdquo; practice area.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessionals tended to use the term \u0026lsquo;breastfeeding\u0026rsquo; in the context of baby-friendly promotion. Others\u0026nbsp;acknowledged the evolving nature of terminology to represent and include various groups of people given the potential implications of using different terms to describe the act of breastfeeding, while also being mindful not to marginalize the majority of those who identify with traditional terminology. Importantly health professionals highlighted the need to be sensitive to individuals based on their own experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is interesting that awareness of the potential for guilt and stigma experienced by women who choose not to breastfeed was identified as a barrier for supporting breastfeeding using the planning card (and other materials) by some professionals. Although understandable, this assumption may inadvertently disadvantage those who are ambivalent or change their mind about feeding method in the perinatal period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA limitation of this small-scale study was lack of representation of diverse populations. All those who took part were all mothers overtly identified as women. We did not purposively seek to recruit participants from marginalized populations and different ethnic/cultural groups were not represented. For future research and development of interventions which could be provided to all parents, it would be advantageous to ensure diversity within the participant population. \u0026nbsp;Additionally the study was carried out in one WHO/Unicef Accredited UK \u0026apos;Baby Friendly\u0026apos; health board area - so may not be representative of the views of women and professionals elsewhere.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study sought to provide insight to the delivery of a breastfeeding planning card as part of a pilot RCT. It aimed to inform the feasibility and acceptability to support longer and more satisfying breastfeeding experiences, and of embedding the planning card within standard antenatal care. When updated to include relevant, realistic advice, and avoid language which may provoke feelings of guilt and anxiety it could be useful in many health service settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePracticalities of embedding the card within standard antenatal care were considered and optimal timing was agreed to be the 32-week antenatal midwife appointment. However, the card showed promise for additional opportunities to be used by health visitors during antenatal and postnatal home visits, hospital postnatal care and even included in the Baby Box, issued by the Scottish Government to all expectant families.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHAPA \u0026ndash; Health Action Process Approach\u003c/p\u003e\n\u003cp\u003eIRAS \u0026ndash; Integrated Research Application System\u003c/p\u003e\n\u003cp\u003eNHS \u0026ndash; National Health Service (UK)\u003c/p\u003e\n\u003cp\u003ePIS \u0026ndash; Participant Information Sheet\u003c/p\u003e\n\u003cp\u003eUNICEF \u0026ndash; United Nations Children\u0026rsquo;s Fund\u003c/p\u003e\n\u003cp\u003eWHO \u0026ndash; World Health Organisation\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by University of Stirling Ethics Committee (NICR \u0026nbsp;2022 8214 6595). UK health service IRAS ethics application was approved by NHS Black Country Research Ethics Committee and by ACCORD NHS Lothian Research and Development office [17-8-22, 22/WM/0168]\u003c/p\u003e\n\u003cp\u003eThe Participant Information Sheet (PIS) was sent to all participants via email upon expressing interest in the study. An information pack containing the PIS and consent form was distributed to participants on the day of the focus groups and signed consent forms were collected by a researcher.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication :\u0026nbsp;\u003c/em\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e: The datasets generated during this study are not publicly available as this may compromise individual privacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests : the Authors \u0026nbsp;declare they have no competing interests.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003eThis study was funded by the Chief Scientist Office for Scotland, Grant Reference HIPS/21/49\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e : A A-A contributed to study design, data collection and analysis and drafting of manuscript. DC contributed to study design, data collection and manuscript preparation. SB collected research data and contributed to analysis and manuscript. AC data analysed and interpreted data, \u0026nbsp;and read manuscript drafts; VS contributed to study design, data analysis and manuscript drafting and completion.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChristie B. Scotland identifies public health priorities. BMJ (Clinical research ed.), 2018;361: k2662. https://doi.org/10.1136/bmj.k2662\u003c/li\u003e\n\u003cli\u003eGuideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017. https://www.who.int/publications/i/item/9789241550086\u003c/li\u003e\n\u003cli\u003eVictora CG, Bahl R, Barros AJD, Fran\u0026ccedil;a GVA, Horton,S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 2016; 387: Issue 10017, 475-490, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(15)01024-7.\u003c/li\u003e\n\u003cli\u003eBlincoe A. The health benefits of breastfeeding for mothers. Br J Midwif. 2005; 13: 398-401. 10.12968/bjom.2005.13.6.18361.\u003c/li\u003e\n\u003cli\u003eBinns C, Lee M, Low WY. The Long-Term Public Health Benefits of Breastfeeding. Asia Pacific J Pub Health. 2016;28(1):7-14. doi:10.1177/1010539515624964\u003c/li\u003e\n\u003cli\u003eModak A, Ronghe V, Gomase KP. The Psychological Benefits of Breastfeeding: Fostering Maternal Well-Being and Child Development. Cureus. 2023 Oct 9;15(10):e46730. doi: 10.7759/cureus.46730. 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Accessed 11/6/25\u003c/li\u003e\n\u003cli\u003eRenfrew M, McAndrew F, Thompson J, Fellows L, Large A, Speed M. \u003cem\u003eInfant Feeding Survey 2010\u003c/em\u003e. 2011, Health and Social Care Information Centre https://sp.ukdataservice.ac.uk/doc/7281/mrdoc/pdf/7281_ifs-uk-2010_report.pdf\u003c/li\u003e\n\u003cli\u003eOlalere O, Harley C. Why women discontinue exclusive breastfeeding: a scoping review. Br J Midwif 2024; 32, 12. https://doi.org/10.12968/bjom.2024.0044\u003c/li\u003e\n\u003cli\u003eScottish Government. Scottish Maternal and Infant Nutrition Survey, 2017. [ data collection]. UK Data Service. 2024 SN: 8477, DOI: http://doi.org/10.5255/UKDA-SN-8477-1.\u003c/li\u003e\n\u003cli\u003eComerford DA, McGillivray T. Effect of obstacles/tips card on breastfeeding drop-off. Br J Midwif, 2021; 29(9), 510-515.\u003c/li\u003e\n\u003cli\u003eBlyth R, Creedy DK, Dennis CL, Moyle W, Pratt J, De Vries SM. Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self‐efficacy theory. Birth, 2002; 29(4), 278-284.\u003c/li\u003e\n\u003cli\u003eUnicef UK Baby Friendly Initiative (2014) Guide to the Unicef UK baby Friendly Initiative Standards, Third Edition. 2014 Guide-to-the-Unicef-UK-Baby-Friendly-Initiative-Standards.pdf\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Cathain A, Hoddinott P, Lewin S, Thomas KJ, Young B, Adamson J, et al. Maximising the impact of qualitative research in feasibility studies for randomised controlled trials: guidance for researchers. Pilot Feasibil Stud; 2015: 1(1). https://doi.org/10.1186/s40814-015-0026-y\u003c/li\u003e\n\u003cli\u003eICH E6 (R3) Guideline for good clinical practice (GCP) EMA/CHMP/ICH/135/1995EMA/CHMP/ICH/135/1995; https://www.ema.europa.eu/en/ich-e6-good-clinical-practice-scientific-guideline\u003c/li\u003e\n\u003cli\u003eBazeley, P, Jackson, K. Qualitative Data Analysis with NVivo (2nd ed.). Qualitative Research in Psychology. 2015; 12: 492-494. 10.1080/14780887.2014.992750.\u003c/li\u003e\n\u003cli\u003eRitchie J, Lewis J. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: Sage Publications Ltd.; 2003.\u003c/li\u003e\n\u003cli\u003eMcCabe R, Katikireddi SV, Dundas R, Craig P. The health impact of Scotland\u0026apos;s Baby Box Scheme: a natural experiment evaluation using national linked health data. Lancet Pub Health. 2023; 8,7: e504 - e510\u003c/li\u003e\n\u003cli\u003eMartinez-Brockman JL, Shebl FM, Harari N, P\u0026eacute;rez-Escamilla R. An assessment of the social cognitive predictors of exclusive breastfeeding behavior using the Health Action Process Approach. Soc Sci Med. 2017 Jun;182:106-116. doi: 10.1016/j.socscimed.2017.04.014. Epub 2017 Apr 12. PMID: 28437693.\u003c/li\u003e\n\u003cli\u003eKwasnicka D, Presseau J, White M, Sniehotta FF. Does planning how to cope with anticipated barriers facilitate health-related behaviour change? A systematic review. Health Psychol Rev. 2013;7(2), 129-145. DOI; 10.1080/17437199.2013.766832\u003c/li\u003e\n\u003cli\u003eZhang CQ, Zhang R, Schwarzer R, Hagger MS. A meta-analysis of the health action process approach. Health Psychol. 2019 Jul;38(7):623-637. doi: 10.1037/hea0000728. Epub 2019 Apr 11. PMID: 30973747.\u003c/li\u003e\n\u003cli\u003eLeeming D, Marshall J, Hinsliff S. Self-conscious emotions and breastfeeding support: A focused synthesis of UK qualitative research. Matern Child Nutr, 2022; 18(1), e13270. https://doi.org/10.1111/mcn.13270\u003c/li\u003e\n\u003cli\u003eGraffy J, Taylor J. What Information, Advice and Support Do Women Want with Breastfeeding? Birth, 2025; 32 (3) 179-186. https://doi.org/10.1111/j.0730-7659.2005.00367.x\u003c/li\u003e\n\u003cli\u003eHoddinott P, Craig LC, Britten J, McInnes RM. A serial qualitative interview study of infant feeding experiences: idealism meets realism. BMJ open, 2012(2), e000504. https://doi.org/10.1136/bmjopen-2011-000504\u003c/li\u003e\n\u003cli\u003eDietrich Leurer, M, Misskey, E. \u0026ldquo;Be positive as well as realistic\u0026rdquo;: a qualitative description analysis of information gaps experienced by breastfeeding mothers. Int Breastfeed J 2015; 10, 10. https://doi.org/10.1186/s13006-015-0036-7\u003c/li\u003e\n\u003cli\u003eOberfichtner K, Oppelt P, Fritz D, Hrauda K, Fritz C, et al. Breastfeeding in primiparous women \u0026ndash; expectations and reality: a prospective questionnaire survey. BMC Preg Childbirth. 2023; 23: 654. https://doi.org/10.1186/s12884-023-05971-1\u003c/li\u003e\n\u003cli\u003eCallahan Churchill A, Davis CG. Realistic orientation and the transition to motherhood. motherhood. J Soc Clin Psychol. 2010; 29, 1: 39\u0026ndash;67. DOI 10.1521/jscp.2010.29.1.39.\u003c/li\u003e\n\u003cli\u003eHarrison M, Hepworth J, Brodribb W. Navigating motherhood and maternal transitional infant feeding: Learnings for health professionals. Appetite. 2018; 121: 228-236, ISSN 0195-6663, https://doi.org/10.1016/j.appet.2017.11.095.\u003c/li\u003e\n\u003cli\u003eFallon VM, Harrold JA, Chisholm A. The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed-methods systematic review. Matern Child Nutr. 2019; 15:e12778. https://doi.org/10.1111/mcn.12778\u003c/li\u003e\n\u003cli\u003eCouto C, Prata AP, Souto SP, Machado J, Viana CR. Nurse and midwife interventions to protect, promote and support breastfeeding: An umbrella review. Midwifery. 2025; 144, 104337, ISSN 0266-6138, https://doi.org/10.1016/j.midw.2025.104337.\u003c/li\u003e\n\u003cli\u003eDieterich R, Caplan E, Yang J, Demirci J. Integrative review of breastfeeding support and related practices in child care centers. J Obs Gyn, \u0026amp; Neonat Nurs. 2020; 49, 1: 5\u0026ndash;15. DOI 10.1016/j.jogn.2019.10.006.\u003c/li\u003e\n\u003cli\u003ePangerl S, Ross-Adije G, Geraghty S, Monterosso L. Sources of breastfeeding knowledge and support skills among midwives and students: a scoping review. Br J Midwif. 2024; 32. 662-671. 10.12968/bjom.2024.0066.\u003c/li\u003e\n\u003cli\u003eBartick MC, Vald\u0026eacute;s V, Giusti A, Chapin EM, Bhana NB, Hern\u0026aacute;ndez-Aguilar MT, et al. (2021). Maternal and Infant Outcomes Associated with Maternity Practices Related to COVID-19: The COVID Mothers Study. Breastfeed Med. 2021; 16(3): 189\u0026ndash;199. https://doi.org/10.1089/bfm.2020.0353\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breastfeeding, Planning Card, Content and Design, Perinatal Care, Health Action Process Approach, Infant Feeding Intervention","lastPublishedDoi":"10.21203/rs.3.rs-6985799/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6985799/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreastfeeding has multiple health benefits for infants and their mothers. \u0026nbsp;Extensive educational and promotional efforts are made by public health initiatives to encourage mothers to initiate and maintain breastfeeding, yet many women experience difficulties and high rates of drop-off at 6-8 weeks of life are noted globally. Development of a breastfeeding planning card focusing on solving common breastfeeding problems may help parents achieve their breastfeeding goals. As part of a feasibility study for implementing the card, focus groups were used to explore the acceptability and feasibility of implementing the planning card delivered by midwives during routine antenatal care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo groups of participants were recruited: one comprising mothers with lived experiences of breastfeeding; and one with health professionals from midwifery, health visiting and infant feeding areas. Focus group discussions aimed to explore acceptability of using a breastfeeding planning card including content, and delivery for pregnant women and feasibility of delivery within routine antenatal care. The focus group aimed to inform reflections and suggest adaptations to the card content and use. Data were analysed using a framework analysis, paying close attention to intervention vulnerabilities and delivery practicalities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBarriers and facilitators of disseminating the card and perceived utility were discussed in focus groups. Overall perspectives were positive regarding content and delivery of the card including content clarity and relevance. Professionals raised some concerns about discrepancies in clinical practice and mothers highlighted conflicting messages which did not align with their experiences of care received. \u0026nbsp;Most interesting were discussions supporting delivery of 'realistic' information to appropriately prepare mothers for breastfeeding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvaluation of acceptability and feasibility of the card was a vital step to address potential barriers and facilitators to implementation. \u0026nbsp;Discussions with targeted groups addressed key questions and supported further card development. Importantly, desirability of this support tool providing realistic breastfeeding information was confirmed by professionals and mothers. \u0026nbsp;\u0026nbsp;The card content was adapted for further testing based on discussions.\u003c/p\u003e","manuscriptTitle":"Would a Planning Card Help New Mothers Achieve their Breastfeeding Goals? Evidence from Focus Groups of Mothers and Health Professionals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-09 14:39:35","doi":"10.21203/rs.3.rs-6985799/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"320744565708785767740597976138753097986","date":"2025-08-14T10:59:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-31T05:48:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-27T13:34:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-26T22:53:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-26T22:52:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-06-26T18:06:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ad4f040-4080-407a-a4da-9cd6aaed1b84","owner":[],"postedDate":"August 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-09T14:39:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-09 14:39:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6985799","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6985799","identity":"rs-6985799","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}