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  • 1. Ahrne, Malin
    et al.
    Adan, Aisha
    Schytt, Erica
    Andersson, Ewa
    Small, Rhonda
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Byrskog, Ulrika
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Antenatal care for Somali born women in Sweden – perspectives from mothers, fathers and midwives2018In: European Journal of Public Health, Volume 28, Issue suppl_1, May 2018, 2018, Vol. 28Conference paper (Refereed)
  • 2. Bergström, Eva-Britt
    et al.
    Wallin, Lars
    Karolinska Institutet.
    Thomson, Gill
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Postpartum depression in mothers of infants cared for in a Neonatal Intensive Care Unit: Incidence and associated factors2012In: Journal of Neonatal Nursing, ISSN 1355-1841, E-ISSN 1878-089X, Vol. 18, no 4, p. 143-51Article in journal (Refereed)
    Abstract [en]

    This longitudinal cohort study investigated the incidence of postpartum depression (PPD) among mothers of infants cared for in two Neonatal Intensive Care Units (NICU) and factors related to PPD onset. 123 mothers were posted the Edinburgh Post-Natal Depression Scale (EPDS) and a questionnaire to record infant and maternal data at 1 month, and a repeat EPDS scale at 4 months post-discharge. PPD incidence was 15% at 1 month, 14% at 4 months, and varied by NICU (23% vs. 8%). Pre-pregnancy and/or antenatal depression was significantly associated with the incidence of PPD. Mothers who experienced PPD at 1 month had an almost eight fold risk of experiencing PPD at 4 months. Women who were not offered counselling during their infant’s stay on the NICU had a 60% increased risk for PPD onset. The findings highlight the need for routine pre-natal screening and targeted support for mothers with infants admitted to NICU.

  • 3.
    Dykes, Fiona
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom; Chinese University of Hong Kong, Hong Kong; University of Western Sydney, Australia .
    Flacking, RenéeDalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Chinese University of Hong Kong, Hong Kong; Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom.
    Ethnographic research in maternal and child health2015Collection (editor) (Other academic)
  • 4.
    Dykes, Fiona
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom; Chinese University of Hong Kong, Hong Kong; University of Western Sydney, Australia .
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Chinese University of Hong Kong, Hong Kong; Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom.
    Introducing the theory and practice of ethnography2015In: Ethnographic Research in Maternal and Child Health / [ed] Fiona Dykes and Renée Flacking, Taylor & Francis, 2015, p. 1-14Chapter in book (Other academic)
  • 5.
    Dykes, Fiona
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. University of Central Lancashire, UK..
    Thomson, G
    Gardner, C
    Hall Moran, V
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Perceptions of European medical staff on the facilitators and barriers to physical closeness between parents and infants in neonatal units2016In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 105, no 9, p. 1039-1046Article in journal (Refereed)
    Abstract [en]

    AIM: Studies have provided insights into factors that may facilitate or inhibit parent-infant closeness in neonatal units, but none have specifically focused on the perspectives of senior neonatal staff. The aim of this study was to explore perceptions and experiences of consultant neonatologists and senior nurses in five European countries with regard to these issues.

    METHODS: Six small group discussions and three one-to-one interviews were conducted with 16 consultant neonatologists and senior nurses representing nine neonatal units from Estonia, Finland, Norway, Spain and Sweden. The interviews explored facilitators and barriers to parent-infant closeness and implications for policy and practice and thematic analysis was undertaken.

    RESULTS: Participants highlighted how a humanising care agenda that enabled parent-infant closeness was an aspiration, but pointed out that neonatal units were at different stages in achieving this. The facilitators and barriers to physical closeness included socio-economic factors, cultural norms, the designs of neonatal units, resource issues, leadership, staff attitudes and practices and relationships between staff and parents.

    CONCLUSION: Various factors affected parent-infant closeness in neonatal units in European countries. There needs to be the political motivation, appropriate policy planning, legislation and resource allocation to increase measures that support closeness agendas in neonatal units. This article is protected by copyright. All rights reserved.

  • 6.
    Ericson, Jenny
    et al.
    Uppsala University; Centre for Clinical Research Dalarna, Falun; Department of Paediatrics, Falu Hospital.
    Eriksson, Mats
    Hellstrom-Westas, Lena
    Hagberg, Lars
    Hoddinott, Pat
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden.
    The effectiveness of proactive telephone support provided to breastfeeding mothers of preterm infants: study protocol for a randomized controlled trial2013In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 13, article id 73Article in journal (Refereed)
    Abstract [en]

    Background: Although breast milk has numerous benefits for infants' development, with greater effects in those born preterm (at < 37 gestational weeks), mothers of preterm infants have shorter breastfeeding duration than mothers of term infants. One of the explanations proposed is the difficulties in the transition from a Neonatal Intensive Care Unit (NICU) to the home environment. A person-centred proactive telephone support intervention after discharge from NICU is expected to promote mothers' sense of trust in their own capacity and thereby facilitate breastfeeding.

    Methods/design: A multicentre randomized controlled trial has been designed to evaluate the effectiveness and cost-effectiveness of person-centred proactive telephone support on breastfeeding outcomes for mothers of preterm infants. Participating mothers will be randomized to either an intervention group or control group. In the intervention group person-centred proactive telephone support will be provided, in which the support team phones the mother daily for up to 14 days after hospital discharge. In the control group, mothers are offered a person-centred reactive support where mothers can phone the breastfeeding support team up to day 14 after hospital discharge. The intervention group will also be offered the same reactive telephone support as the control group. A stratified block randomization will be used; group allocation will be by high or low socioeconomic status and by NICU. Recruitment will be performed continuously until 1116 mothers (I: 558 C: 558) have been included. Primary outcome: proportion of mothers exclusively breastfeeding at eight weeks after discharge.

    Secondary outcomes: proportion of breastfeeding (exclusive, partial, none and method of feeding), mothers satisfaction with breastfeeding, attachment, stress and quality of life in mothers/partners at eight weeks after hospital discharge and at six months postnatal age. Data will be collected by researchers blind to group allocation for the primary outcome. A qualitative evaluation of experiences of receiving/providing the intervention will also be undertaken with mothers and staff.

    Discussion: This paper presents the rationale, study design and protocol for a RCT providing person-centred proactive telephone support to mothers of preterm infants. Furthermore, with a health economic evaluation, the cost-effectiveness of the intervention will be assessed. Trial registration: NCT01806480

  • 7.
    Ericson, Jenny
    et al.
    Uppsala University; Centre for Clinical Research Dalarna, Falun; Department of Paediatrics, Falu Hospital.
    Eriksson, Mats
    Hellström-Westas, Lena
    Hoddinott, Pat
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Proactive telephone support provided to breastfeeding mothers of preterm infants after discharge: a randomised controlled trial2018In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 107, no 5, p. 791-798Article in journal (Refereed)
    Abstract [en]

    AIM: The aim was to evaluate the effectiveness of proactive telephone support provided to breastfeeding mothers of preterm infants after discharge from neonatal intensive care units (NICU).

    METHODS: Between March 2013 and December 2015, a randomised controlled trial was conducted at six NICUs across Sweden. At each NICU, a breastfeeding support team recruited, randomised and delivered the support to participating mothers. The intervention group received a daily proactive telephone call up to 14 days after discharge from the support team. The control group could initiate telephone contact themselves. Primary outcome was exclusive breastfeeding eight weeks after discharge. Secondary outcomes were maternal satisfaction with breastfeeding, attachment, quality of life and parental stress.

    RESULTS: In total, 493 mothers were randomised, 231 to intervention group and 262 to control group. There were no differences between the groups for exclusive breastfeeding, odds ratio 0.96, 95% CI 0.66-1.38, nor for maternal satisfaction with breastfeeding, attachment or quality of life. The intervention group reported significantly less parental stress than the controls, t=2.44, 95% CI 0.03-0.23, effect size d=0.26.

    CONCLUSION: In this trial, proactive telephone support was not associated with increased exclusive breastfeeding prevalence eight weeks following discharge. However, intervention group mothers showed significantly lower parental stress. This article is protected by copyright. All rights reserved.

  • 8.
    Ericson, Jenny
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Uppsala universitet, Centre for Clinical Research Dalarna, Falu lasarett.
    Eriksson, Mats
    Hoddinott, Pat
    Hellström-Westas, Lena
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Breastfeeding and risk for ceasing in mothers of preterm infants - long-term follow-up2018In: Maternal and Child Nutrition, ISSN 1740-8695, E-ISSN 1740-8709, Vol. 14, no 4, article id e12618Article in journal (Refereed)
    Abstract [en]

    Breastfeeding is challenging for mothers of preterm infants. The aim of this paper is to describe risk factors for ceasing breastfeeding and methods of feeding until 12 months postnatal age in mothers who breastfed their preterm infants at discharge from neonatal intensive care units (NICUs). The data come from a randomised controlled trial, which evaluated the effectiveness on exclusive breastfeeding at 8 weeks of proactive telephone support compared with reactive support offered to mothers of preterm infants following discharge from NICU. Six NICUs across Sweden randomised a total of 493 mothers. We used regression and survival analyses to assess the risk factors for ceasing breastfeeding and the long-term outcomes of the intervention. The results showed that 305 (64%) of the infants were breastfed at 6 months and 49 (21%) at 12 months. Partial breastfeeding at discharge, low maternal educational level, and longer length of stay in the NICU increased the risk for ceasing breastfeeding during the first 12 months. Furthermore, the Kaplan-Meier analysis showed that the proportion of mothers who ceased breastfeeding did not differ between the intervention (n = 231) and controls (n = 262) during the first 12 months (log-rank test p = .68). No difference was found between groups on method of feeding. More than 85% of the infants were fed directly at the breast. These findings provide important insights for health professionals who are supporting mothers of preterm infants to breastfeed long term.

    Registered in www.clinicaltrials.gov (NCT01806480).

  • 9.
    Ericson, Jenny
    et al.
    Department of Paediatrics, Falu Hospital.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Estimated breastfeeding to support breastfeeding in the neonatal intensive care unit2013In: Journal of Obstetric, Gynecologic and Neonatal Nursing, ISSN 0884-2175, E-ISSN 1552-6909, Vol. 42, no 1, p. 29-37Article in journal (Refereed)
    Abstract [en]

    Objective. To evaluate the effects of estimated breastfeeding on infant outcomes in comparison to test weighing and to describe staff members experiences of estimated breastfeeding as a method for supporting the transition from tube feeding to breastfeeding.

    Design. A mixed method evaluation. Setting Neonatal Intensive Care Unit (NICU) in Sweden. Participants The study included 365 preterm (25th36th gestational weeks) infants and 45 nurses or nurse assistants. Methods A retrospective comparative medical record study was used to assess infant outcomes during a period of test weighing (196 infants) and again after the implementation of estimated breastfeeding (169 infants). A qualitative survey was conducted to explore the staff experiences of estimated breastfeeding.

    Results. No differences were found between groups regarding duration of tube feeding, length of hospital stay, gestational age, weight at discharge, and rate of any breastfeeding. Infants in the estimated breastfeeding group had a higher risk of not being exclusively breast milk fed than infants in the test-weighing group (OR = 2.76, CI [1.5, 5.1]). Staff perceived estimated breastfeeding as a more facilitative and less stressful method for mothers than test weighing. Some staff had difficulty following guidelines while simultaneously providing person-centered care.

    Conclusions. Estimated breastfeeding is a nonintrusive and feasible method for assessing and supporting the transition from tube feeding to breastfeeding among preterm infants in a NICU. However, the increased risk for not being exclusively breastfed is of concern. Additional research is needed to assess whether this method is appropriate and feasible in varying contexts and cultures. JOGNN, 42, 29-37; 2013. DOI: 10.1111/j.1552-6909.2012.01423.x

  • 10.
    Ericson, Jenny
    et al.
    Uppsala University; Centre for Clinical Research Dalarna, Falun; Department of Paediatrics, Falu Hospital.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hellström-Westas, Lena
    Eriksson, Mats
    Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units: a register study over 10 years2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, article id e012900Article in journal (Refereed)
    Abstract [en]

    Objective: There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants.

    Design, setting and participants: This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004–2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups.

    Results: From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22–27 weeks) from 55% to 16%, in very preterm (GA 28–31 weeks) from 41% to 34% and in moderately preterm infants (GA 32–36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding and which became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants).

    Conclusions: In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.

  • 11.
    Ericson, Jenny
    et al.
    Uppsala University; Centre for Clinical Research Dalarna, Falun; Department of Paediatrics, Falu Hospital.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Udo, Camilla
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Mothers' experiences of a telephone-based breastfeeding support intervention after discharge from neonatal intensive care units - a mixed-method study2017In: International Breastfeeding Journal, ISSN 1746-4358, E-ISSN 1746-4358, Vol. 12, no 1, article id 50Article in journal (Refereed)
    Abstract [en]

    Background: After discharge from a neonatal intensive care unit (NICU), many mothers of preterm infants (gestational age<37 weeks) experience a lack of support for breastfeeding. An intervention study was designed to evaluate the effects of proactive (a daily telephone call initiated by a member of a breastfeeding support team) and/or reactive (mothers could call the breastfeeding support team) telephone based breastfeeding support for mothers after discharge from the NICU. The mothers in the intervention group had access to both proactive and reactive support; the mothers in the control group only had access to reactive support. The aim of this study was to explore the mothers' experiences of the proactive and reactive telephone support.

    Methods: This study was a qualitatively driven, mixed-method evaluation using three data sources: questionnaires with qualitative open-ended questions, visual analogue scales and telephone interviews. In total, 365 mothers contributed data for this study. The qualitative data were analysed with an inductive thematic network analysis, while the quantitative data were analysed with Student's t-test and the chi-square test.

    Results: Proactive support contributed to greater satisfaction and involvement in breastfeeding support. The mothers who received proactive support reported that they felt strengthened, supported and secure, as a result of the continuous care provided by staff who were knowledgeable and experienced (i.e., in breastfeeding and preterm infants), which resulted in the global theme 'Empowered by proactive support'. The mothers who received reactive support experienced contradictory feelings; some felt secure because they had the opportunity to call for support, whereas others found it difficult to decide when and if they should use the service, which resulted in the global theme; 'Duality of reactive support'.

    Conclusion: There were positive aspects of both proactive (i.e., greater satisfaction and feelings of empowerment) and reactive support (i.e., the opportunity to call for support); however, the provision of reactive support alone may be inadequate for those with the greatest need for support as they are the least likely to access it.

  • 12. Finlayson, Kenneth
    et al.
    Dixon, Annie
    Smith, Chris
    Dykes, Fiona
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, UK.
    Mothers’ perceptions of family centred care in neonatal intensive care units2014In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 5, no 3, p. 119-124Article in journal (Refereed)
    Abstract [en]

    Objective: To explore mothers' perceptions of family centred care (FCC) in neonatal intensive care units (NICUs) in England. 

    Design: The qualitative experiences of 12 mothers from three NICUs in the UK were elicited using individual interviews. A thematic network analysis was conducted on the transcribed interviews. 

    Main outcome measures: A central global theme supported by a number of organizing themes were developed reflecting the views of the mothers and their experiences of FCC. 

    Results: A global theme of "Finding My Place" was identified, supported by six organizing themes: Mothering in Limbo; Deference to the Experts; Anxious Surveillance; Muted Relations, Power Struggles and Consistently Inconsistent. Mothers experienced a state of liminality and were acutely sensitive to power struggles, awkward relationships and inconsistencies in care. To try to maintain their equilibrium and protect their baby they formed deferential relationships with health professionals and remained in a state of anxious surveillance. 

    Conclusions: This study illustrates that despite the rhetoric around the practice of FCC in NICUs, there was little in the mother's narratives to support this. It is of the utmost importance to minimize the consequences of the liminal experience, to improve staff-mother interactions and to facilitate mothers' opportunities to be primary caregivers. 

  • 13.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Amning och utbildning: hur hänger det ihop?2010In: Barnläkaren, ISSN 1651-0534, no 4, p. 19-20Article in journal (Refereed)
  • 14.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Feeding preterm infants in Sweden: challenges to implementing the Global Strategy in a pro-breastfeeding culture2009In: Infant and Young Child Feeding : Challenges to implementing a Global Strategy / [ed] Dykes, Fiona; Hall Moran, Victoria, Oxford: Wiley-Blackwell , 2009, p. 43-56Chapter in book (Other academic)
  • 15.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    The neonatal environment and the long-term impact of neonatal care2018Other (Other (popular science, discussion, etc.))
  • 16.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Breili C, C
    Eriksson, M
    Facilities for presence and provision of support to parents and significant others in neonatal units2019In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 108, no 12, p. 2186-2191Article in journal (Refereed)
    Abstract [en]

    AIM: To describe parental facilities for staying in neonatal units, visiting policies, and access to emotional support during hospitalization.

    METHODS: A cross-sectional design was used in which a survey was presented to all neonatal units in Sweden; 34 out of 38 units participated (89%).

    RESULTS: The findings showed that in 50% of the units, parents could stay 24/7 for the infant's entire hospital stay. In 32% of the units, siblings could stay the night with their parents. Units had policies on restrictions for visits by siblings (80%), grandparents (59%), friends and relatives (71%). All units offered counselling to parents, and some units offered peer-to-peer groups (24%), diaries (35%), relaxation techniques (6%) or internet parental forums (6%). All units enabled parents to be at home with their infant and to visit the unit for check-ups (35%) or to have staff visits at home (65%).

    CONCLUSION: Facilities for parents to stay with their infant during hospitalization and to have significant others visit are good, but there is room for improvement. During the transitional phase to being at home, parents are facilitated in being at home before the infant is discharged and are supported by the unit, which must be considered beneficial for parents. This article is protected by copyright. All rights reserved.

  • 17.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK.
    Dykes, Fiona
    University of Central Lancashire.
    ‘Being in a womb’ or ‘playing musical chairs’: the impact of place and space on infant feeding in NICUs2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, article id 179Article in journal (Refereed)
    Abstract [en]

    Background: Becoming a parent of a preterm baby requiring neonatal care constitutes an extraordinary life situation in which parenting begins and evolves in a medical and unfamiliar setting. Although there is increasing emphasis within maternity and neonatal care on the influence of place and space upon the experiences of staff and service users, there is a lack of research on how space and place influence relationships and care in the neonatal environment. The aim of this study was to explore, in-depth, the impact of place and space on parents’ experiences and practices related to feeding their preterm babies in Neonatal Intensive Care Units (NICUs) in Sweden and England.

    Methods: An ethnographic approach was utilised in two NICUs in Sweden and two comparable units in England, UK. Over an eleven month period, a total of 52 mothers, 19 fathers and 102 staff were observed and interviewed. A grounded theory approach was utilised throughout data collection and analysis.

    Results: The core category of ‘the room as a conveyance for an attuned feeding’ was underpinned by four categories: the level of ‘ownership’ of space and place; the feeling of ‘at-homeness’; the experience of ‘the door or a shield’ against people entering, for privacy, for enabling a focus within, and for regulating socialising and the; ‘window of opportunity’. Findings showed that the construction and design of space and place was strongly influential on the developing parent-infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding.

    Conclusions: If our proposed model is valid, it is vital that these findings are considered when developing or reconfiguring NICUs so that account is taken of the influences of spatiality upon parent’s experiences. Even without redesign there are measures that may be taken to make a positive difference for parents and their preterm babies.

  • 18.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dykes, Fiona
    Creating a positive place and space in NICUs2014In: The Practising Midwife, ISSN 1461-3123, Vol. 17, no 7, p. 18-20Article in journal (Other (popular science, discussion, etc.))
  • 19.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Chinese University of Hong Kong, Hong Kong; Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom.
    Dykes, Fiona
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom; Chinese University of Hong Kong, Hong Kong; University of Western Sydney, Australia .
    Cross-national ethnography in neonatal intensive care units2015In: Ethnographic Research in Maternal and Child Health / [ed] Fiona Dykes and Renée Flacking, Taylor & Francis, 2015, p. 89-116Chapter in book (Other academic)
  • 20.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dykes, Fiona
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Encouraging breastfeeding: a relational perspective2010In: Early Human Development, ISSN 0378-3782, E-ISSN 1872-6232, Vol. 86, no 11, p. 733-736Article in journal (Refereed)
    Abstract [en]

    Despite the WHO recommendations that babies should be breastfed exclusively for six months and thereafter for up to two years and beyond this pattern of feeding is far from the global norm. Although breastfeeding is triggered through biological mechanisms which have not changed with time, the perception of breastfeeding as a phenomenon is variable, as it not only reflects cultural values of motherhood but is also negotiable from the perspective of the individual. This paper argues that relationships are central to encouraging breastfeeding at an organisational, family and staff–parent level. This shifts our conceptualisations away from the primary focus of breastfeeding as nutrition which, in turn, removes the notion of breastfeeding as a productive process, prone to problems and failure.

  • 21.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dykes, Fiona
    Perceptions and experiences of using a nipple shield among parents and staff: an ethnographic study in neonatal units2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, no 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Preterm infants have an immature sucking behavior and the capacity to be exclusively breastfed may be reduced for a period of weeks or months, depending on gestational age. Nipple shields have been used, not only as a device to help mothers with sore nipples, but also to facilitate the infant's latch on to the breast. However, the benefits of using nipple shields have been debated. The aim of this study was to explore perceptions and experiences of using a nipple shield among parents and staff in neonatal units in Sweden and England.

    METHODS: An ethnographic study was undertaken where observations and interviews were conducted in four neonatal units in Sweden and England. The data were analyzed using a thematic networks analysis.

    RESULT: The global theme was developed and named, 'Nipple shield in a liminal time'. This comprised of two organizing themes: 'Relational breastfeeding' and 'Progression'. 'Relational breastfeeding' was underpinned by the basic themes, 'good enough breast', 'something in between' and 'tranquil moment'. 'Progression' was underpinned by the basic themes, 'learning quicker', 'short-term solution' and 'rescue remedy'. Although breastfeeding was seen primarily as a nutritive transaction, the relational aspects of breastfeeding were of crucial importance. These two organizing themes show the tension between acknowledging the relational aspects of breastfeeding and yet facilitating or supporting the progression of breastfeeding in the period from tube feeding or cup feeding to breastfeeding. It is a liminal time as mothers and their infants are "in between" phases and the outcome, in terms of breastfeeding, is yet to be realized.

    CONCLUSION: This study demonstrates parents' and staffs' perceptions of the nipple shield as a short term solution to help initiation of breastfeeding but also as a barrier between the mother and infant. It is important that the mother and baby's own particular needs are taken into account, in a person-centred way and on an ongoing basis. Furthermore, we need to emphasise the importance of the 'relational' whilst understanding the need for 'progression'. Holding these in balance may be the key to appropriate use of the nipple shield.

  • 22.
    Flacking, Renée
    et al.
    Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden; Center for Clinical Research Dalarna, SE-791 82 Falun, Sweden; Department of Paediatrics, Falun Hospital, SE-791 82 Falun Sweden.
    Dykes, Fiona
    Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Public Health and Clinical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK.
    Ewald, Uwe
    Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden.
    The influence of fathers’ socioeconomic status and paternity leave on breastfeeding duration: a population based cohort study2010In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 38, p. 337-343Article in journal (Refereed)
    Abstract [en]

    Aim: The propensity to breastfeed is a matter of public concern because of the favourable effects for infants. However, very few studies have described the influence of paternal variables upon duration of breastfeeding. The aim of this study was to describe the effects of fathers’ socioeconomic status and their use of paternity leave on breastfeeding duration for infants up to 1 year of age. Methods: A prospective population-based cohort study was undertaken. Data on breastfeeding, registered in databases in two Swedish counties for 1993—2001, were matched with data on socioeconomic status and paternity leave obtained from Statistics Sweden. Fathers of 51,671 infants were identified and included. Results: Infants whose fathers had a lower level of education, were receiving unemployment benefit and/or had a lower equivalent disposable household income were significantly less likely to be breastfed at 2, 4, 6, 9, and 12 months of age. Infants whose fathers did not take paternity leave during the infant’s first year were significantly less likely to be breastfed at 2 (p < 0.001), 4 (p < 0.001), and 6 months (p < 0.001). Conclusions: This paper shows that an enabling of an increased involvement from fathers during the infants’ first year of life, such as by paid paternity leave, may have beneficial effects on breastfeeding up to 6 months of age. A more systematic approach to supporting fathers’ involvement may be particularly valuable to those infants whose fathers have a lower socioeconomic status.

  • 23.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Hedberg Nyqvist, Kerstin
    Starrin, Bengt
    Trustful bonds: A key to “becoming a mother”and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit2006In: Social Science & Medicine, ISSN 0277-953, Vol. 62, no 1, p. 70-80Article in journal (Refereed)
    Abstract [en]

    A preterm birth and subsequent hospitalization of an infant at a neonatal unit (NU) implies an extraordinary life situation for mothers, in which the maternal role and breastfeeding begin and evolve in a medical and unfamiliar setting. Descriptions of how women experience “becoming a mother” and breastfeeding in such a situation are sparse and this question was addressed in the present study. In this qualitative study, inspired by the grounded theory approach, in-depth interviews were conducted with 25 mothers whose very preterm infants had been cared for in seven NUs in Sweden. Findings indicated the importance of quality in social bonds with the infant, father, staff and other mothers at the NU, for “becoming mothers” and experiencing mutually satisfying breastfeeding. Three themes comprised a structure for descriptions of experiences, social bonds and mediated emotions: (1) ‘loss’ of the infant and the emotional chaos—“putting life on hold”; (2) separation—a sign of being unimportant as a person and mother; and (3) critical aspects of becoming more than a physical mother. The qualities were described as trustful or distrustful, characterized by accompanying feelings of pride/trust or shame/distrust. Social bonds were affected not only by the interpersonal interplay but also by the public environment and care routines. In conclusion, the contextual setting and distrustful social bonds impaired the ability to “become mothers” and the sensation of reciprocity i.e. breastfeeding becoming dutiful and not mutually satisfying. As breastfeeding is an intimate interplay and a personal choice it was considered that the best breastfeeding support would seem to be provision of a favorable environment that enhances the mother's confidence in herself. The contextual setting should be modeled such as to create conditions for a trustful and reciprocal mother–infant bond.

  • 24.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Starrin, Bengt
    “I wanted to do a good job”: Experiences of ‘becoming a mother’ and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit neonatal unit2007In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 64, no 12, p. 2405-2416Article in journal (Refereed)
    Abstract [en]

    In mothers of preterm infants, the process of becoming a mother is initiated in a public and medical environment, in which the mothers become dependent on the benevolence and support of the staff. This setting and an experience of insecure social bonds impair the ability to become a mother during the infant's stay at the neonatal unit (NU), and breastfeeding may become a duty and not be mutually satisfying. Studies on how women experience becoming a mother and breastfeeding after the infant's discharge are sparse and this question is addressed in the present grounded theory study. Twenty five mothers, whose very preterm infants had received care in seven NUs in Sweden, were interviewed once, 1–12 months after discharge. We propose a model to increase understanding of the process of becoming a mother and breastfeeding, after the infant's discharge from the NU. The mother's emotional expressions in this process showed pendular swings from feeling emotionally exhausted to feeling relieved, from experiencing an insecure to a secure bond, and from regarding breastfeeding as being non-reciprocal to being reciprocal. Unresolved grief, the institutional authority at the NU and experiences of shame were three of the central barriers to a secure and reciprocal relationship. The pendular changes give us a deeper understanding of the variations in both attachment and attunement. Perhaps the negative extremes are more prominent among these mothers on account of their infant's illness and their NU experiences. If our proposed model is valid, it is vital that these findings are considered by those involved in the short- and long-term care in order to support the mothers to establish a secure bond, comprising both attachment and attunement.

  • 25.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Wallin, Lars
    Perinatal and socioeconomic determinants of breastfeeding duration in very preterm infants2007In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 96, no 8, p. 1126-1130Article in journal (Refereed)
    Abstract [en]

    Aim: To describe the impact of prematurity, size at birth, neonatal disorders and the families' socioeconomic status (SES) on breastfeeding duration in mothers of very preterm infants.

    Methods: Prospective population-based cohort study. Data on breastfeeding, registered in databases in two Swedish counties in 1993–2001, were matched with data from two national registries: the Medical Birth Registry and Statistics Sweden. Mothers of 225 very preterm singleton infants were identified and included.

    Results: Seventy-nine percent of the mothers breastfed at 2 months, 62% at 4 months, 45% at 6 months, 22% at 9 months and 12% at 12 months. Prematurity, size at birth and neonatal disorders did not show an effect on breastfeeding duration. Being adversely exposed to any of the SES factors (maternal education, unemployment benefit, social welfare and equivalent disposable income in the household) was significantly associated with earlier weaning up to 6 months of infants' postnatal age.

    Conclusions: This study shows new and noteworthy results concerning breastfeeding duration in mothers of very preterm infants, which was not influenced by degree of prematurity, size at birth or neonatal disorders but was affected by SES. This highlights the need for improved support of socioeconomically disadvantaged mothers, during and after the hospital stay.

  • 26.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Wallin, Lars
    Karolinska Institutet.
    Positive effect of Kangaroo Mother Care on long-term breastfeeding in very preterm infants2011In: Journal of Obstetric, Gynecologic and Neonatal Nursing, ISSN 0884-2175, E-ISSN 1552-6909, Vol. 40, no 2, p. 190-197Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate the use of Kangaroo Mother Care (KMC) and its association with breastfeeding at 1 to 6 months of corrected age in mothers of very preterm (VPT) and preterm (PT) infants.

    Design: Prospective longitudinal study. Setting: Neonatal Intensive Care Units in four counties in Sweden. Participants: The study included 103 VPT (<32 gestational weeks) and 197 PT (32-36 gestational weeks) singleton infants and their mothers.

    Methods: Data on KMC, measured in duration of skin