Treading a fine line in equitable breastfeeding support: balancing breastfeeding promotion while avoiding pressure to breastfeed - a realist evaluation.

BACKGROUND: Breastfeeding support is most effective when delivered face-to-face, yet professionals must balance tensions between promotion, maternal autonomy, and rapport across diverse families. The contextual mechanisms shaping this support, particularly motherhood norms, remain underexplored. Drawing on cultural health capital theory, this study unfolds the relational dynamics of breastfeeding support, exploring how health visitors in a Danish breastfeeding intervention balanced adherence to professional recommendations without provoking feelings of breastfeeding pressure equitably among mothers in different socioeconomic positions.

METHODS: Applying a realist evaluation approach, data consisted of 35 home visit observations, 6 focus groups with 34 health visitors and 16 individual interviews with mothers. This study was part of a comprehensive evaluation of the Danish Breastfeeding - a good start together intervention.

RESULTS: In seeking to promote breastfeeding in line with professional recommendations while avoiding pressure on mothers in lower socioeconomic positions, health visitors sometimes undermined their support by downplaying their expertise. Health visitors' reticence in offering explicit breastfeeding support - intended to protect mothers from feeling pressured - was perceived by mothers as a lack of support and professionalism.

CONCLUSION: In breastfeeding support, professionals' efforts to avoid pressure and reliance on tacit assumptions about families' feeding decisions may reduce proactive support and reinforce breastfeeding inequities. This highlights the need for professional reflexivity in a field often marked by guilt and shame.