Table 4 Additional quotes from interviewees

Theme 1: Health professionals’ approaches to childbirth and breastfeeding

Medicalization of childbirth and breastfeeding

N7

… and of course, sometimes you intervene, you can’t help it.

N8

… one is used to give a bottle when mothers say they think to have insufficient breastmilk, because then breastfeeding problems are settled. Convincing mothers and supporting them that they don’t stop, but rather continue, that’s really difficult.

M11

There are nurses, child nurses [on the ward]. There are lactation counselors, those who are IBCLC-certified, but often it’s these strict rules rather than caring on an individual basis…

P12

Of course, I’m convinced about the benefits of breastfeeding and women should possibly be supported to be able to breastfeed. Even after discharge, they should still wish to breastfeed rather than stopping it because they’re too stressed. It’s good […] for their [babies’] physical condition. For the immune response and the like and for mothers…

M8

Besides, I’ve the impression that nipple shields are used quite fast and quite often… I don’t know the specific reasons, whether it’s then easier for nurses to support breastfeeding.

Naturalness of childbirth and breastfeeding

P1

Midwives also provide reasons for it [BFHI] and [they outline] that it’s very important for the bonding between mother and baby, that this is really substantial. Concerning antibodies, we know from medicine that it’s relevant… [Midwives emphasize] again and again, that it’s crucial for the close relationship between mother and baby.

M8

If the mother has delivered under my supervision and if I’ve seen that breastfeeding works without nipple shields but this [giving nipple shields] will be the first intervention after 3 h, I’ll go to the nurse and ask her directly why this is necessary?

M3

This whole process starts with increasing salivation among babies. Fascinating, really and due to this oozy cheeks they can slip to it, I mean, you have to consider this, how genial nature is.

M10

Give [mothers] security that nature has prepared them. Of course there are sometimes exceptions, that not every mother can [breastfeed].

Theme 2: Collaboration in the face of professional and structural boundaries

Professional jurisdictions

N5

After c-section, you need the anesthesiologist, the gynecologist, the pediatrician, the midwife, sometimes an additional nurse … The problem about this is again, these habitual jurisdictions…

N7

Because when there are lactation problems, then you’ve to ask for a gynecologist, because this problem is a problem that relates to mothers, thus, mother issues, they relate to gynecologists.

P7

Because it [delivery] changes the focus, I become less and less interesting as gynecologist, before, I’m the most interesting person for the mother.

P10

Following our system, it’s midwives who are responsible for the labor room and who take care of mothers up to a few hours after delivery. Then mothers will be handed over to nurses. From then on, nurses are responsible for taking care and counselling.

M10

… there is some little exchange [between midwives and nurses] when moving mothers from the labor room to the ward. Otherwise, there is hardly any exchange, well, we’re really separated divisions.

P7

… because we don’t have any executive power. Anesthesiologists have their work area and are responsible for this area. In the beginning they said, no one is allowed to enter the operating theatre because they are responsible. In the end, you run against a wall and you can’t overcome it because it’s right, it’s his [the anesthesiologist’s] area.

P2

As we’re [gynecologists] only responsible for ward rounds on the maternity ward and as we aren’t present on the ward the whole day, it [breastfeeding counseling] belongs to the responsibility of the respective nurse…

P10

As long as they [mothers] have no baby, I’m not involved as a pediatrician. I don’t know, we’ve discussed repeatedly how much of an issue breastfeeding is once women reach the end of their pregnancy.

Spatial division of maternity units

N9

They’re really isolated in their labor room although the labor room and the ward are next to each other. To get to the labor room, you even have to pass the ward, but still, we don’t know every name of every midwife… there isn’t a strong connection.

P13

Because during daily work there outside [on the ward], I think…

M10

But it would make sense to handover all issues which we’ve [midwives] already explained to her [the mother], which breastfeeding position we’ve shown, thus a little bit more elaborated. Also outside on the ward, … there should be more explicit handovers

Theme 3: Strategies to harmonize professional approaches with BFHI implementation

Safeguarding and defense strategies

N2

… you have a standard which specifies who does what, where does he/she conduct it, when is it conducted.

N6

If you don’t have any standards or any points of reference or how shall I say, guidelines, it’ll slip somehow and after a while you’ll return to old practices.

M10

Well it’s just, probably to shape it consistently, there are standards, and then the individual interpretation is often neglected [by nurses]. Well, I hardly appreciate that.

M11

For me, Baby-Friendly means to act in an individual manner, but… nurses want to hear: if this than that, and that. But this isn’t applicable to breastfeeding and maternity and child care.

Circumvention strategies

M3

However, even in my case, there are aspects [of BFHI] which I refuse. For example, the standard or guideline that every woman has to get skin-to-skin contact directly after c-section, I cannot sign this.

N9

… the anesthesiologists, they think, it [BFHI] isn’t relevant to them… they think it [BFHI] won’t bother them.

P1

I can only remember that during one night shift it was said at 3.00 am, that we’ve to do skin-to skin contact. I’ve to say, I’ve denied it. Everything was so exciting and the father ran around

P1

Well we, the anesthesiologists hardly have to do anything with it [BFHI)…

N9

Well, it’s, midwives are really self-confident, it’s a really self-confident professional group.

P13

The team of gynecologists is quite fragmented. Really fragmented, there is a break between advocates and refusers, i.e. physicians who don’t feel responsible for breastfeeding.