The study’s final substantive theory is generated through integration of the core category, Promoting optimal breastfeeding through the osteopathic therapeutic cycle, with other key conceptual findings. It offers a more summative and complete explanation of the study as a whole and is represented by Figure 8. The substantive theory’s Inter-related conceptual findings consist of contextual determinants, the core problem, the core category and four categories and their strategies and sub-strategies. Undertaking the final integration is one of the key characteristics of grounded theory methodology158. Corbin contends that the cues to theory building lie in the researcher’s ability to gain insight from the data and
“make the scheme work” (Corbin & Strauss, 2008, p. 274)159. In order to illustrate how the resultant theory ‘works’, in a practical sense, in the situation of osteopaths treating babies with breastfeeding difficulties, its theoretical underpinnings are discussed as they apply to one specified clinical case and participant group. Comparisons are then made with other
158 See Chapter 3.5.7.
159 Credibility and trustworthiness of qualitative and grounded theory studies is discussed in Chapter 4.9.
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Figure 8: The substantive theory
CORE CATEGORY
The Osteopathic Therapeutic Cycle
Optimal Breastfeeding
• Effective
• Personalised
• Fulfilling
Facilitating Positive Change
Integrating Creating the
Therapeutic Space
Assimilating
Connecting Empowering
Rebalancing Women’s Views & Experience
• Personal choices & expectations
• Advice & expectations of others
Osteopaths’ Professional Identity
• The osteopath’s perspective
• Perspective from outside the profession
Health Care as a Commodity
• Health literacy
• Shopping around
CONTEXTUAL DETERMINANTS
CORE PROBLEM
Struggling to Breastfeed Satisfactorily
• Facing Uncertainty
• Experiencing Distress
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cases to illuminate commonalities and differences and to show how the overarching theory can be applied in individual ways.
The exemplar case involves Vivienne, a 30 year-old first time mother of six-week old baby Amanda, who is treated by Tom (osteopath). Tom is in his fifth year of practice and thus represents one of the least experienced osteopaths in the study. Unlike the other three male osteopath participants, who are fathers; he has a history of limited personal experience with babies. He is, however, interested and comfortable with treating babies and enjoys paediatric practice. This is Vivienne and Amanda’s third visit and, on this occasion, they are accompanied for the first time by father, Steve.
The obstetric history is complicated as labour commenced with Vivienne unaware that the baby was in a breech position. She experienced medical difficulties and the baby was delivered by an emergency caesarean section. Steve and Vivienne had planned, and were committed, to breastfeed. They come from a family background where breastfeeding is considered normative and they were aware of its health advantages. They describe the decision to breastfeed as a shared, easy and normal new parenting expectation. Elements of this contextual background are similarly reported by other mothers. Most had complicated births and describe feeling distressed and disappointed by perinatal events.
All have supportive partners who play a key role in assisting and encouraging them to breastfeed. Unlike Vivienne, however, most women were more analytical regarding their decision-making around infant feeding, which was informed by a belief that breastfeeding was natural and the best option, but not necessarily normative and, at times, different to other family members’ expectations.
Vivienne describes a scenario of confusion and uncertainty surrounding the birth. She left the hospital, however, believing that breastfeeding was progressing normally.
We didn’t realise that there was a real [breastfeeding] problem ... I thought we were doing fairly well; just thought we’d fine tune it. Then they weighed her and found that she had lost a fair bit of weight (Vivienne, M 03/01).
Vivienne faces further uncertainty relating to breastfeeding when, at a follow-up domiciliary visit, the maternal child health nurse reports that baby Amanda has a dysfunctional suck. Vivienne, who was referred to Tom by a lactation consultant had no prior knowledge of osteopathy but expresses an open-minded view to complimentary therapies and reflects on her experiences of the health services made available to her on becoming a mother.
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I don’t really feel like it [osteopathy] should be something that’s rightfully offered to everyone. You could seek it out if you want to. There’s been so much government funded support of all kinds that I haven’t really felt the whole experience to be financially a strain. Um, I can’t really speak for anyone else but in my opinion if you felt that you needed it, you try to find a way (M 03/18).
This exemplar illustrates a common finding of the study; that women think about themselves as consumers of health services and osteopathy is situated within the private sector. While Vivienne accepts financial responsibility for osteopathic treatment, women participants have a range of views on the personal and social implications of the notion of health-care as a commodity and paediatric osteopaths demonstrate awareness of this contextual determinant’s potential influence on their clinical practice. In the current case, Tom knows that he needs to earn Vivienne’s trust and describes the most effective means to do this as achieving positive treatment results.
On the first two visits, Tom follows a course of action conceptualised as the osteopathic therapeutic cycle to get to know Vivienne and Amanda, define or diagnose their breastfeeding problem, and respond accordingly. He creates a therapeutic space by building interpersonal relationships through the strategies of Connecting. He gains knowledge by uncovering the nature of the clinical problem through Focusing, Analysing and Validating information; the strategies of Assimilating. He interprets examination findings according to what he feels in Amanda’s body and which he believes are a result of forces sustained during her birth and he links physical findings, conceptually, to her suck dysfunction.
Amanda had that posterior drag through the head but she was also compressed down through the middle face into her anterior neck and chest. So that then held down the front [causing] a bit of restriction to her lifting her head up and getting the tongue on the roof of her mouth properly (O 3/03).
Before commencing treatment, Tom ensures that Vivienne understands and feels comfortable with his diagnostic analysis and intended treatment approach by using the strategies of Forming an Alliance and Building Trust. Vivienne states, “He (Tom) explained sufficiently what he was doing. And I was comfortable with just kind of trusting to what he was doing (Vivienne, M 3/11).
Like Vivienne, mothers generally describe osteopaths’ interpretations of their birth histories and physical findings in the babies’ bodies as insightful and believable. Typically,
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they need to trust in osteopaths’ integrity and knowledge because paediatric osteopathy is not well known to them or to significant others; a situation that includes health practitioners who are involved, at the same time, in their care. The contextual determinants of Women’s views and experiences and Osteopaths’ professional identity impact in various ways on how mothers and osteopaths articulate and define the core problem and how they form comfortable and cooperative practitioner-patient relationships.
On the third visit, Tom re-connects with Vivienne and Amanda by discussing their breastfeeding progress and develops an introductory relationship with father Steve, who has some understanding of the situation and paediatric osteopathy based on Vivienne’s account of events and Amanda’s responses. After some preliminary discussion, Steve was observed to place Amanda carefully onto the treatment table and, with Vivienne, sit close by her. Tom sits opposite them and places his hands lightly and deliberately on either side around her pelvis. He is still and maintains this hand contact while Amanda, who is awake and visibly content, wriggles and slowly uncurls to adopt a more symmetrical and relaxed position. Mother and father have relaxed facial expressions as they gaze at their baby and occasionally smile at her and each other. Overall, it is observed to be a calm, quiet, and intimate scene.
This part of the osteopathic therapeutic cycle involves the transitional theme of Facilitating positive change. Tom is applying manual therapy and draws on the strategies of Rebalancing, which are Tuning-in and Releasing and Activating. As Amanda lies on the table in her ‘natural’ twisted posture, Tom adopts a global manual treatment approach by applying one technique that appears to influence her body posture as a whole. He explains his thoughts and actions as follows.
Yes, well she (Amanda) had a little bit of a false midline … her physical tissues were more comfortable off to that right side which is why she doesn’t like turning her head to the left …. You’re getting all the information coming into your hands;
you just sense it, I suppose, and then they (babies) kind of rebalance themselves
… as things started moving back to a more normal position, she was more comfortable to adopt that easy straight position.
Tom chooses a subtle form of indirect manual technique to release abnormal physical tensions and achieve a state of improved physiological balance. He reasons that one technique or therapeutic cycle suffices for this particular session because a positive change has occurred, driven by the baby’s self-adjusting postural mechanisms and visibly apparent. Throughout this process, a comfortable and attentive silence is maintained.
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When the technique is finished, however, signalled by Tom removing his hand contact, the tempo of interaction shifts immediately from quiet to busy. Participants stand up, the baby is picked up, and an interactive discussion takes place about the current situation and future plans.
Positive changes of a less overt psychosocial nature are likely to have also taken place through the parents relaxing and acquiring a deeper understanding of Amanda’s developmental changes. Parental awareness is reinforced through inclusion and the opportunity to observe Amanda’s bodily responses and general demeanour, particularly when interacting with Tom. Vivienne states, “I can see a visible difference in her as she’s being treated. Like her jaw has certainly come out, she pokes her tongue out more easily (M3/15)”. Physical responses become linked logically through explanation and by signs of a stronger coordinated suck and overall improved breastfeeding self-efficacy. Vivienne’s current approach to breastfeeding involves a complex mix of feeding strategies that she summarises as follows.
A typical feed for us at the moment is she goes on the breast for 20 minutes total;
10 minutes each side; then has a bottle. Then [she] goes back on the breast for another 10 minutes each side; just to try and give her a chance to do it herself first.
And then, [I] give her some bottle and that seems to actually make her suck better.
So she then goes back on me and sucks better and swallows better (M 3/02).
It is apparent that Vivienne and Amanda are working out breastfeeding together, each in her own way. Amanda’s suck is improving and Vivienne is assuming control of a difficult breastfeeding situation. She is empowered by a growing sense of confidence and mastery of breastfeeding, which is encouraged by Tom. Steady progress in this dyad’s breastfeeding capabilities is generally reported, which suggests that smaller positive changes accrue as one therapeutic cycle plays into the next cycle. Over time, sequential changes are integrated in a meaningful way that results in a smooth transition toward optimal breastfeeding.
For Vivienne and Amanda, the end goal of effective breastfeeding appears to be realistic and achievable. This case, however, represents one of a range of therapeutic approaches, treatment responses, and breastfeeding outcomes that were observed to take place throughout the conduct of the study. Not all babies were able to cooperate so well and osteopaths adjusted their therapeutic approaches accordingly. For example, mothers might be recruited to play a more active role in distracting or soothing the baby during treatment and osteopaths might need to adjust treatment positions and
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expectations. The concept of optimal breastfeeding differs according to individual circumstance, which, in turn, influences treatment strategies and aims. For example, Tania (mother) first brings baby Charlie, aged 14 weeks to Julie (osteopath) because he is generally unsettled, a poor sleeper, and has fed exclusively from one breast because he refuses to feed from the other breast. She is frustrated by his behaviours but he is putting on weight and developing normally. Julie identifies significant somatic dysfunctions160 in Charlie’s body that restrict his neck mobility and deduces that these findings are implicated in his behaviour patterns. She focuses less on the specific breastfeeding problem and more on restoring normal physical function and helping Tania understand the postulated physical causes of Charlie’s breast refusal and other difficult behaviours.
Understanding assists Tania to accept and cope with their current breastfeeding relationship, which is personally frustrating but successfully meeting Charlie’s nutritional needs. Tania expresses regret that she didn’t seek osteopathic treatment earlier and we cannot know how new insights or creating new meanings161 might influence their future breastfeeding relationship, but Julie predicts the following outcome.
That his [Charlie’s] general health will be improved by the structural [physical]
changes and an understanding for the mum that is was OK to be going the way that she was going and there was a reason for it (Julie, O 1/12).
Promoting mothers’ understandings of their breastfeeding situations and validating their struggles is a common therapeutic goal. Despite different breastfeeding difficulties and individual needs, paediatric osteopaths are able to respond satisfactorily by using a common schema; the osteopathic therapeutic cycle. Regardless of the final breastfeeding outcome; overall, each mother believed that she and her baby received some benefits through their interaction with the osteopath and would recommend osteopathy to other dyads with breastfeeding difficulties.