This is a preprint copy of the text prior to print review.
For the full published work please see:
Brown, A., Raynor, P., & Lee, M. (2011). Young mothers who choose to breast feed: the importance of being part of a supportive breast-feeding community. Midwifery, 27(1), 53-59.
Young mothers who choose to breastfeed: The importance of being part of a supportive breastfeeding community
Amy Brown, Peter Raynor and Michelle Lee
School of Human Sciences
Swansea University
Singleton Park
Swansea
SA2 8PP
Corresponding author:
Amy Brown
Department of Psychology
School of Human Sciences
Swansea University
Swansea
UK
SA2 8PP
Tel: +44 (0)1792 295281
Email:
Abstract
To investigate the factors associated with breastfeeding initiation and duration in a sample of young mothers (< 24 years), 138 mothers (mean age 21.93 years) completed a retrospective questionnaire about their experience of breast or formula feeding their infant during the first six months postpartum. A further ten mothers who breastfed for at least six months completed a semi structured interview. Eighty three point three per cent of mothers initiated breastfeeding at birth, with 27.6% breastfeeding for at least six months. Breastfeeding initiation was positively associated with family background, attitudes and sources of support. Breastfeeding duration was positively associated with attending a breastfeeding support group, believing breastfeeding to be easy, being in an environment where breastfeeding is normative and being encouraged to breastfeed by others. Themes raised through the interviews included viewing breastfeeding as the norm, support from family and friends and believing breastfeeding to be easier than formula feeding. The findings raise important issues for targeting breastfeeding interventions.
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Keywords: breast-feeding; infant; age; breastfeeding duration; formula-feeding
1
Introduction
Breastfeeding has been shown consistently to have benefits for both infant and maternal health. Rates of gastrointestinal and respiratory disorders1, eczema2, obesity3, otitis media4 and allergies5are higher in formula-fed infants,whilst women who formula feed have an increased risk of reproductive cancers6and osteoporosis.7 The World Health Organisation recommends that infants are breastfed exclusively for the first six months of life with continued breastfeeding up to the second year and beyond.8In the UK, however, only 76% of mothers initiate breastfeeding at birth and by six months only 22% of mothers are giving any breast milk at all.9
Moreover, breastfeeding rates are not equal across allsocial groups. Duration of breastfeeding is positively associated with age, level of education, income and socioeconomic status.10 - 15Younger mothers are less likely to initiate breastfeeding and if they do so, to breastfeed for a shorter duration. Recent figures from the UK Infant Feeding Survey show that whilst 76% of mothers across the sample initiated breastfeeding at birth, only 52% of those aged 20 and under did so. Mothers in this age group were also particularly prone to a short duration of breastfeeding with only 34% of this age group breastfeeding by one week. By six months postpartum, mothers aged 35 or over were five times more likely still to be breastfeeding than those aged 20 and under. 9
Reasons for formula use or a short duration of breastfeeding amongst younger mothers are numerous and well documented. One barrier to breastfeeding initiation is the actual or perceived attitude of society towards breastfeeding. Mothers report feeling uncomfortable or embarrassed and lack confidence breastfeeding in front of others.16Moreover, beliefs about the supposed difficulty of breastfeeding are widespread and publicised.17Whilst formula feeding is viewed as easy and simple and associated with greater freedom, breastfeeding is viewed as painful, inconvenient and embarrassing.18, 19Mothers approaching breastfeeding with a “give it a go” attitude expect to encounter problems. 20
Familial background and experience of breast or formula feeding plays an important role for younger mothers and is often a stronger influence than that of health professionals.21Younger mothers in particular are influenced heavily by attitudes and experiences of family and friends, even though they themselves are wary to admit so.18 However, many mothers report feeling that they are part of a “bottle feeding culture” where bottle feeding is accepted and breastfeeding ridiculed.22 Many have no family history of breastfeeding and findknowledge and experience of bottle feeding to be stronger amongst family and friends.20However, mothers who themselves were breastfed are more likely to go on to breastfeed, 23as are those who hear positive stories about breastfeeding.24
Support from others has been shown to be a key issue in breastfeeding success.25However, persuasion by other family members for younger mothers to formula feed is common. Mothers are encouraged to use formula becausegrandparents feel excluded 17, or so that she can leave her infant more easily with others to have a break. 26Reports of ridicule from peers for attempting to breastfeed are common, particularlybecauseit is seen as tying to the infant.27The mother’s partner also has a strong influence over infant feeding choice. A partner who is supportive of breastfeeding is associated with increased breastfeeding duration.24However many younger mothers report using formula because their partner felt left out.20 Finally support from health professionals appears to be an important element to sustained breastfeeding. 28However, many younger mothers report that they felt health providers did not support them enough in their decision. 27Finally knowledge and confidence are strongly associated with breastfeeding duration.17, 28, 29Low confidence and self efficacy 29 and feeling ill prepared to breastfeed however are common amongst younger mothers. 30
Here we investigate through both survey and extended interview the factors associated with breastfeeding duration in younger mothers. Through exploring the experiences of mothers who breast fed despite being part of a social group where formula use was common, it was hoped that insight could be gained as to how to provide support to women in this age group more effectively.
Methods
Participants
We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research. Approval for this study was granted by the Swansea University Department of Psychology Research Ethics Committee.One hundred and thirty eight mothers who were aged 24 years or younger at the time of childbirth completed the questionnaire(mean age 21.93 years). Participants had at least one child aged between 6 months and 24 months of age (mean age 12.94 months, SD: 5.29) and had started consuming complementary food at the time of the questionnaire. 89% of the participants were primiparous. Multiparous mothers were asked to complete the questionnaire in relation to their youngest child. Ten mothers who breastfed until six months or more further took part in a semi structured interview about their reasons for and experiences of breastfeeding until this time. Participants were recruited from mother and baby groups in South West Wales and online parenting forums based in the UK.
Measures
Participants completed a series of questions about their attitudes and beliefs about infant feeding, their actual experience of infant-feeding, and general demographic information. Participants completed the questionnaires retrospectively as they were asked to answer the questions in relation to their youngest or only child from when they were born to 6 months of age, when milk was the primary source of nutrition. Ten participants completed a semi structured interview investigating themes such as experiences of breastfeeding, support, others attitudes and suggestions for increasing breastfeeding duration amongst younger mothers. All identifying information was removed from these responses. Responses are identified by first initial and maternal age at childbirth. The basic interview schedule can be found in appendix one.
Background information
Participants provided demographic information; age at childbirth, years in education, maternal employment before the birth, maternal and paternal occupation, household income, home ownership and marital status (Table 1). Occupations were coded according to the National Statistics Socio – Economic Classification self – coded method (NS – SEC). (31) Participants also provided infant birth weight and gestational age at birth. Infants were excluded from the analysis if they had a low birth weight (< 2500g) or were born prematurely (< 37 weeks). 32
Infant feeding method
Participants gave information about breastfeeding duration up to the sixmonth postpartum (180 days). All mothers (n = 117) initiated breast-feeding at birth with a range of 1 to 180 days.27.6% continued until at least six months post partum. 37.9% of mothers who initiated breastfeeding discontinued within the first three days post partum. 84.4% of mothers who breastfed until six months reported using formula milk only occasionally or never.
Attitudes and experiences surrounding Breast and Formula Feeding
Using a retrospective self report questionnaire, participants completed a series of questions looking at their attitudes, experiences and sources of prenatal advice and postnatal supportwhen giving their infant milk feeds during the first six months postpartum. Respondents were asked to rate a series of statements using a five point likert scale (agree to disagree).An exploratory factor analysis was used to produce dimensions for comparison. A high loading point of 0.5 for the factor analysis, producing five factors associated experience of breastfeeding, six associated with attitudes and six for sources of advice and support. Experience factors included maternal confidence, partner’s support of breastfeeding, being surrounded by others who breastfed, encouraged to breastfeed by others, maternal conviction to breastfeed. Attitudes included breastfeeding as difficult, breastfeeding as inconvenient, breastfeeding as embarrassing, formula fed infants as easier, formula feeding as the norm and breastfeeding as best for health. Sources of both prenatal and postnatal advice were grouped into familial, professional and specialist. These factors and the questions which loaded onto them can be found in appendix two.
Additionally participants were asked about the timing of their decision on how to feed their infant (before pregnancy, first trimester, second trimester, third trimester or after birth), whether they attended antenatal classes or a breastfeeding support group and if they knew whether they themselves or their partner had been breast or formula fed.
Data analysis
The factor analysis was carried out using SPSS v13, SPSS UK Ltd. The factor scores computed were saved as regression scores and used for the data analysis as recommended by Tabachnik and Fidell (2006).33 T tests were used to establish differences in experience and attitudes of those who chose to formula feed or initiate breastfeeding at birth. Pearson’s correlations were used to further analyse the association between attitudes and experiences and breastfeeding duration for those who initiated breastfeeding at birth. A stepwise multivariate linear regression analysis was performed to identify attitudes and experiences independently predictive of breastfeeding duration.
Results
Breast or formula milk at birth
Attitudes and experiences of mothers who initiated breastfeeding (n = 117) were compared to those who used formula milk from birth (n = 23). Mothers who breastfed at birth were significantly less likely to believe breastfeeding to be inconvenient [t (132) = -3.113, p < 0.001], embarrassing [t (132) = -5.643, p < 0.001], that most people formula fed these days or that formula fed infants were easier and more settled [t (132) = -3.078, p < 0.01 and more likely to believe breastfeeding to be better for infant and maternal health [t (132) = 6.87, p < 0.001]. No significant difference was seen between the groups for the attitude breastfeeding as difficult.
Sources of support and information also differed between the two groups. Mothers who initiated breastfeeding were significantly less likely to seek information before the birth from family and friends [t (131) = -3.74, p < 0.01] but significantly more likely to see information from specialist sources [t (131) = 2.130, p < 0.05]. No difference was seen between the two groups for seeking information from health professionals. If information or support was needed after the birth, those who breastfed were significantly more likely to seek advice from specialist sources [t (121) = 2.138, p < 0.05] but significantly less likely to seek advice from family or friends [t (121) = -3.672, p < 0.001] or health professionals [t (121) = -3.33, p < 0.001].
Mothers who initiated breastfeeding came from a different background to those who used formula at birth. They were significantly more likely to be surrounded by family and friends who breastfed their children [t (132) = 6.545, p < 0.001], to be encouraged to breastfeed [t (132) = 6.503, p < 0.001] and to have a partner supportive of breastfeeding [t (132) = 5.446, p < 0.001]. Moreover mothers who breastfed were more likely to themselves have been breastfed [χ² (1, 112) = 6.372, p < 0.01]. They were also significantly more likely to have attended antenatal classes than mothers who formula fed at birth χ² (1, 138) = 91.535, p < 0.001].Mothers who initiated breastfeeding at birth also made the decision earlier on in pregnancy on how to feed their infant [t (132) = -3.948, p < 0.001] and to feel that they ‘should’ breastfeed [t (132) = 7.397, p < 0.001]
Factors associated with breastfeeding duration
The following analyses were based on mothers who initiated breastfeeding at birth (n = 117). A number of factors were significantly associated with breastfeeding duration (see table two). Increased breastfeeding duration was associated with having a partner who was supportive of breastfeeding, being part of an environment where breastfeeding was accepted and the norm, being encouraged to breastfeed by others, feeling confident about infant feeding and seeking prenatal advice and postnatal support from specialists such as breastfeeding counsellors. Mothers who made the decision earlier on in, or before their pregnancy to breastfeed, breast – fed for a longer duration. Negative attitudes were significantly inversely associated with breastfeeding duration. Beliefs that breastfeeding was inconvenient, difficult, that formula fed infants were more settled and that formula feeding was the norm were associated with a shorter breastfeeding duration.
Increased breastfeeding duration was seen for mothers who attended antenatal classes [t (11) = 3.554, p < 0.001] and breastfeeding support groups [t (114) = 8.992, p < 0.001]. Breastfeeding duration was also greater for mothers who had themselves been breastfed [t (93) = 4.728, p < 0.001] or believed their infants father to have been breastfed [t (64) = 2.654, p < 0.05].
No significant association was seen between breastfeeding duration and the belief that breastfeeding was best for infant and maternal health. The means showed that regardless of breastfeeding duration mothers appeared to believe breastfeeding was better for infant health than formula milk.
Predictors of breastfeeding duration
Each significant indicator of breastfeeding duration was placed in a forward stepwise linear regression with breastfeeding duration as the outcome measure. Attending a Breastfeeding support group, believing breastfeeding to be easy, being in an environment where breastfeeding is the norm and being encouraged to breastfeed by others remained significant predictors of breastfeeding length [Adjusted R square = .757; F (4, 85) = 67.338, p < 0.001].
Semi structured interviews
The interview findings revealed important aspects surrounding breastfeeding initiation and duration amongst younger mothers who breastfed for at least six months. They raise important issues which could be used to understand breastfeeding intention amongst younger mothers and to target resources appropriately. Key findings included the ideas that breastfeeding was the normal and natural way to feed an infant alongside immersion in an environment where breastfeeding was common, supported and normal. Mothers were not void of difficult experiences or the negative reactions of others but overcame these issues due to their beliefs as to the importance of breastfeeding and that they had nothing to be ashamed or worried about. Finally mothers provided thoughts as to ways in which breastfeeding support could be tailored to improve breastfeeding duration amongst younger mothers.
Longstanding intention to breastfeed
All of the mothers interviewed recalled knowing that they would breastfeed before they became pregnant. Many stated that there was no choice to be made.
I trusted my instincts and knew that it was the best thing for my daughter, there was no decision to be made. (T, 18)
I believe that having the choice to how to feed your baby is where the problem starts! If breastfeeding was considered the normal way to feed your baby and formula only used when this was not possible, then mothers wouldn’t be so confused about having to choose and would breastfeed with confidence. (F, 18)
Breastfeeding as natural and normal
A common theme was the idea that breastfeeding was the natural way to feed an infant and that was what breasts were intended for. A number of mothers raised the idea that feeding an infant with the milk from another species seemed incredulous.
For me it was just a “given” that I would use my breast for the purpose they were designed for (K, 21)
It is incredibly important, this is the baby’s first taste of nutrients outside the womb... surely it makes more sense to give our babies tailored made milk rather than that for an animal? (B, 19)
Believing breastfeeding as the easier option
Numerous studies have shown that younger mothers often give reasons of the inconvenience or difficulty of breastfeeding when choosing formula. Mothers here however, who breastfed successfully, often felt it was a more convenient and easier method than formula feeding.
I am too darn lazy to be faffing with bottles/powder etc and we didn’t get the free milk tokens and we could not afford the milk so I thought that no matter what this baby would get breastfed and I stuck at it! (K, 21)
It just seems the easier option to me – its more convenient, I don’t have to get up in the night or make up bottles or worry when I’m out – its always there, always ready and always at the right temperature. I don’t think it ties you at all to the baby – I think it gives you independence (C, 20)
Enjoyment from breastfeeding
All mothers reported finding breastfeeding to be a positive experience. Rather than simply being a means to nourish their infant, mothers recalled enjoying the experience and feeling sad, yet proud once it was over.
How nice it is to snuggle with baby when feeding, not having to cart loads of stuff with me, being able to crack an eye lid latch baby on and doze off a bit when feeding in bed at night (K, 21)
I loved everything about breastfeeding and still do! Breastfeeding came so naturally and felt normal. I was confident in my ability as a mother and felt pride in the fact that my baby was getting everything she needed from me still and was happy and thriving! It’s been the best experience of my life and we’re still enjoying it now.