The mother continues to describe how the pregnancy visit and early establishment of rapport resulted in her reaching out to the health visitor before the first planned postpartum visit because she experienced breastfeeding difficulties within the first days after birth:
Thus, by establishing trust prenatally and thereby removing the pressure from the families postpartum, we find that they reach out to their health visitor postpartum when they experience breastfeeding difficulties. By allowing the family to meet the health visitor while they are still capable of practicing control over the formal meeting, the family maintain a feeling of self-respect, which evens out parts of the power imbalance and assists in building a more equal relationship between the health visitor and the family.
2.3 The families’ previous experiences
Turning to the family and the individual contextual factors, and drawing upon Luhmann, trust requires a degree of choice and thereby agency but also resembles structure in that it reduces complexity in the future (29). According to Luhmann, to obtain a structuring effect in the future the agency to display trust or distrust – the decision to either behave in a certain way or to hold certain expectations – is profoundly “embedded within a whole host of events, decisions and structures which have earlier taken place” (30). Hence, current choices to trust are constrained by earlier events and decisions and past experiences and hence become a contextual factor that greatly influences how a family enters the meeting with their health visitor. Past experiences pertaining to trust forms momentary action because of an embeddedness in an ongoing process rather than a fully conscious one-off decisiveness. In our case, past experiences pertaining to trust in health- or social care providers structures the current encounter with the health visitor. As two intertwined layers, the welfare state context structures the context of the family and the dynamics through which the family can choose to trust the health visitor. The following passage from an interview with a second-time mother, who previously had been sick with severe depression illustrates how a former experience with the system affected her expectations. When asked about her expectations towards meeting her new health visitor the mother replied:
‘… it is not someone I know-know, so perhaps I need to be careful with opening up, because if I come clean, will she use it against me? I do not know. The thought has sometimes crossed my mind. That I need to be careful with what I say because could she use it against me… or does she actually want to help me? You do not know them that well, do you?’ (mother of two)
The mother continues with reflections about why distrust automatically is a starting point for her:
’I don’t know, maybe you are afraid to say everything. Tell everything. That was the feeling I was left with the first time, but not the second time around. Now I am like ”you know what, don’t you dare come take my kids”… I have been on sick leave with depression before. So maybe they are watching me more closely. Yes, they monitor you in a way. ”Does she know how to be a mother?”, “Can she take care of her kids after she has been sick even if she is not on medication or anything and is functioning normally now?”’ (mother of two)
Her past experiences with the social system and previous feeling of being monitored shape how this mother enters the meeting with her new health visitor. Distrust, based on past experiences, becomes a structuring factor for her current behavior and a contextual factor that greatly influences the activation of a mechanism of trust.
3.1. Successful establishment of trust
Numerous reasons for and characteristics of a trustful relationship with the health visitor were pointed out by the participating mothers. Generally, and roughly categorized, the vulnerable mothers, who perceived the health visitor as a potential threat due to the inherent authoritative power imbalance highlighted the importance of confidentiality when it came to trust. A mother of two expressed that to trust her health visitor, she needed confidentiality:
‘That you can rely on and trust that what you tell her will stay between the two of you’ (mother of two)
Mothers, for whom the power imbalance was not a major concern, described how the health visitors’ self-presentation and professional experience and knowledge was important. A striking tendency across cases with insecure/worried mothers or mothers with previously bad experiences with the health care system was the general fear of being judged by the health visitor. To them a trusting relationship was formed through the health visitor’s non-judgmental and supportive approach with genuine praise and encouragement. When asked why this mother of three, who earlier was a young mother alone with two kids, characterizes her relationship with the health visitor as trustful, she replied:
‘It may sound stupid but back when I became a single mom… It was damn difficult to keep a full-time job, take care of the kids, and everything… So she has seen me at my worst. And even then, she didn’t judge me. I think that is how I feel. Because I feared that someone would mark me as a bad mother. That is why I kept my full-time job, the house, the car and the garden… Everything looked nice. You know. All that. It was extremely important to me. I totally forgot myself in the process’ (mother of three)
The same mother, who previously had two failed attempts at establishing breastfeeding, continues to explain how her current health visitor through genuine praise and encouragement increased her self-efficacy related to breastfeeding:
‘The support and the “Come on, you are doing it right!”. That is what is in my head when she (the health visitor) says: “You are doing great with breastfeeding” then it is because we indeed are doing great with breastfeeding’ (mother of three)
Besides confidentiality, professional experience, a secure self-presentation and a non-judgmental and supportive approach, across cases mothers described how trust in the health visitor was strongly aligned with her ability to focus on what was actually important to the family – her ability to tailor her support to the individualized needs of the family was of major importance for the establishment of trust whether it being ignoring the messiness of the home and instead focusing only on the kids, recognizing that the grandmother was an important part of the mother’s life and a source of support, or accepting a home with animals as expressed by a first-time mother below:
‘We feared that she would comment negatively on the fact that we have cats because they have their own mentality, but she didn’t say anything. So, we have a great relationship so far’ (first-time mother)
To practice tailoring, a distinctive feature regarding the health visitor’s approach to the families was evident: she had to approach the family in a calm way and decode their needs before introducing her own agenda, as expressed in the quote below, where a distrustful and previously depressed mother who despite having concerns about the forthcoming collaboration with the new health visitor postpartum, ended up with a very trustful relationship. When asked what her health visitor had done to establish a trustful relationship between them, the mother replied:
‘… it is probably about trust in the health visitor. The way they approach you. You know, quietly and peacefully, they sit down and observe who you are rather than leaving you with a feeling of being taken aback. There are too many emotions at stake when you have a newborn… I think sometimes you feel taken aback in your own home. Monitored. I don’t know. I did, at least the first time around’ (mother of two)
The health visitors expressed that the conditions for the decoding and tailoring process are more advantageous during the pregnancy visit compared to the early visits postpartum. When asked what is special about the pregnancy visit compared to visits postpartum a health visitor replied:
‘The pregnancy visit provides you with that trustful relationship, which makes it easier when you visit next and there is a baby. Then the guard has been lowered and we can skip the politeness and icebreakers and instead dive straight into the important stuff… I think it is the most important visit. Really, a solid foundation’ (health visitor)
One health visitor equated the pregnancy visit to getting ’a head start’ and as a way to ‘kickstart the relationship formation with the family’. By meeting prior to birth, the health visitor can form an early impression of the family and their social situation and thereby tailor her subsequent support to meet their individualized needs and preferences. Tailoring is enabled because the family is usually not yet in a chaotic and overwhelmed state compared to right after birth and the health visitor can therefore obtain a more nuanced insight into the family’s social situation, their strengths and weaknesses, as expressed by a health visitor below:
‘Their strengths and weaknesses stand out more clearly during the pregnancy visit, because once the baby is there, it is like they forget everything about themselves’ (health visitor)
The process of tailoring their breastfeeding support also entails a strong sensitivity towards the family’s prior experiences with breastfeeding or expectations and wishes regarding breastfeeding among first-time parents. Health visitors point to that knowledge hereof is difficult to obtain during the early visits postpartum because the parents are usually exhausted and perhaps in pain after giving birth. The pregnancy visit and the tailored breastfeeding support early postpartum become important also among mothers with previous negative breastfeeding experiences as illustrated in the quote below:
‘It (the pregnancy visit) gives you a good opportunity to correct their previous breastfeeding stories. If they have had bad breastfeeding experiences in the past, maybe because there was not sufficient milk... Together we can figure out what the problem actually was. So they become better prepared’ (health visitor)
Tailoring related to previous experiences with breastfeeding or breastfeeding expectations are about correction of causal explanations of breastfeeding difficulties, breastfeeding preparation in terms of validated evidence, and perhaps most importantly tracking down how important breastfeeding is to the family. By identifying the family’s perceived importance of breastfeeding the health visitor can tailor her subsequent support to meet their needs and avoid situations where the family feels pressured into breastfeeding as expressed by a health visitor below:
‘Then there is something in relation to what is my role going to be here. How far should I go to support and push you, right’ (health visitor)
Obtaining clarification about breastfeeding wishes and expectation alignment in relation to breastfeeding support prior to birth (how do you prefer I support you if breastfeeding challenges occur?) is extremely important given the aforementioned power imbalance between the health visitor and the family. The pregnancy visit allows for alignment and clarification of expectations which strongly enhances the trust between the health visitor and the family and prevents situations where a family feels pressured into breastfeeding.
3.2 When trust is not established
We now turn to look at cases where the intervention failed to establish a trustful relationship and therefore did not reach the outcome of improved breastfeeding support. Several contextual factors influenced the activation of a mechanism of trust.