Why some women do not breast feed: bottle feeding and fathers' role

Bottle-feeding practice and its associated factors among mothers of children aged 0 to 23 months in sub-Saharan Africa: a multi-level analysis of demographic and health surveys (2015-2022)

BACKGROUND

Avoidance of bottle feeding is recommended as it interferes with optimal suckling behavior, is difficult to keep clean, and is an important route for the transmission of pathogens. However, there is a current shift towards breastfeeding for a short period and the introduction of bottle feeding in both the developed and developing worlds. Bottle-feeding practice and its individual- and community-level determinants are not addressed in sub-Saharan Africa. Therefore, this study aimed to fill this gap and assess the pooled prevalence and associated factors of bottle feeding among mothers of children less than 23 months of age.

METHODS

Data from the recent demographic and health surveys of 20 countries in sub-Saharan Africa conducted between 2015 and 2022 were used. A total weighted sample of 86,619 mother-child pairs was included in the current study. Multilevel mixed-effects logistic regression was used to determine the factors associated with the outcome variable. Intra-class correlation coefficient, likelihood ratio test, median odds ratio, and deviance (-2LLR) values were used for model comparison and fitness. Finally, variables with a p-value < 0.05 and an adjusted odds ratio with a 95% confidence interval were declared statistically significant.

RESULTS

The overall pooled prevalence of bottle feeding among mothers of children aged 0 to 23 months in sub-Saharan Africa was 13.74% (95% CI: 13.51%, 13.97%). Factors like maternal age [AOR = 1.09; 95% CI (1.04, 1.14)], educational status [AOR = 2.83; 95% CI (2.58, 3.10)], marital status [AOR = 1.16; 95% CI (1.09, 1.24)], maternal occupation [AOR = 0.76; 95% CI (0.73, 0.79)], media exposure [AOR = 0.80; 95% CI (0.76, 0.85)], wealth index [AOR = 1.21; 95% CI (1.15, 1.29)], sex of the household head [AOR = 1.17; 95% CI (1.12, 1.24)], family size [AOR = 1.06; 95% CI (1.01, 1.12)], number of under-five children [AOR = 1.11; 95% CI (1.04, 1.19)], place of delivery [AOR = 1.06; 95% CI (1.00, 1.12)], mode of delivery [AOR = 1.41; 95% CI (1.31, 1.52)], counseling on breastfeeding [AOR = 0.88; 95% CI (0.84, 0.92)], age of the child [AOR = 1.65; 95% CI (1.57, 1.75)], and residence [AOR = 1.64; 95% CI (1.56, 1.72)] were significantly associated with bottle-feeding practices.

CONCLUSION

Nearly one out of seven children aged 0 to 23 months received bottle feeding in sub-Saharan African countries. Older mothers, higher mothers' educational status, unmarried women, richest families, non-working mothers, exposed to media, female-headed households, large family size, having one under-five children, home delivery, cesarean delivery, children aged 6-11 months, and urban residence were significantly associated with an increased risk of bottle feeding. Breastfeeding promotion programs are advised to target mothers who are older, educated, working, rich, gave birth at home, have a large family size, are delivered by cesarean section, have children aged 6-11 months, and reside in urban areas to achieve a significant decrease in bottle feeding rates in sub-Saharan Africa.

Newborn Feeding Knowledge and Attitudes among Medical Students

This study sought to assess newborn feeding knowledge and attitudes among medical students. A sample of 649 Portuguese medical students completed an online survey containing a sociodemographic questionnaire, the Newborn Feeding Ability Questionnaire (NFA), and the Iowa Infant Feeding Attitudes Scale (IIFAS). The overall sample showed moderate scores for all variables. Gender analysis identified significant differences only for the dimension related to the benefits of skin-to-skin contact between mother and newborn where women scored higher. Analysis by year of training found that students with more years of training scored higher on all variables of newborn feeding knowledge that were positively correlated and were positive predictors of newborn feeding attitudes. Students with fewer years of training scored higher on work practices interfering with newborn feeding ability, which were negatively correlated and were negative predictors of newborn feeding attitudes. These results demonstrate that medical students with more years of training are the most prepared, however, the moderate results of the sample raise concerns. Our results point to the importance of providing medical students with adequate knowledge in order to influence their attitudes toward newborn feeding and contribute to better working practices for future health professionals.

Factors affecting the mother's choice of infant feeding method in Poland: a cross-sectional preliminary study in Poland

BACKGROUND

The World Health Organization identifies exclusive breastfeeding as the gold standard for child nutrition. Breastfeeding provides many benefits to both the baby and the mother. First days after birth are crucial for breastfeeding and determining its further path. Unfortunately, very often it is also the time of facing the first breastfeeding problems. The aim of this study was to analyse selected factors influencing a mother's decision to breastfeed.

METHODS

This is a cross-sectional study conducted between March 2019 and November 2019 in selected Polish maternity wards. Data were collected through completion of author's questionnaire and a standardised questionnaire and the Multidimensional Perceived Social Support Scale and also through informal interviews with mothers. During statistical analysis, the chi-square test of independence and the Kolmogorov-Smirnov test as well as the non-parametric Mann-Whitney U test in addition to Fisher's exact test were performed.

RESULTS

The results showed that there is no correlation between the mode of delivery and the mother's choice of infant feeding method. Knowledge of the benefits of breastfeeding and received support affects the mother's decision on infant feeding method. The study also showed that the 83% of newborns were put to the breast within the first 2 h after birth. However, only 58% continued to be breastfed in the subsequent days. As many as 42% of the newborns were supplemented with formula despite early initiation of breastfeeding. Analyses showed that exclusive breastfeeding was more often chosen by mothers with higher education. And the most common breastfeeding problem reported by 62% of the respondents was perceived insufficient milk supply and also breastfeeding pain, reported in 48.5% mothers.

CONCLUSIONS

It is extremely important to continually promote breastfeeding among women. The role of midwives is crucial in this regard, as they should encourage the initiation of breastfeeding, support mothers during the perinatal and postnatal periods, and increase their sense of competence and confidence in their ability to breastfeed. Accessible, professional, and empathetic support can help reduce the number of women supplementing with modified milk. Undoubtedly, the postpartum period is important for breastfeeding outcomes, but it is significant that breastfeeding education and promotion begin during pregnancy.

Choking, allergic reactions, and pickiness: A qualitative study of maternal perceived threats and risk avoidance strategies during complementary feeding

An infant's early eating experiences influence later growth and health. However, motivators for mothers' complementary feeding decisions for their infants, such as the process of introducing solid foods, remains unclear. This qualitative study identified maternal perceived threats surrounding complementary feeding and strategies mothers use to mitigate perceived threats of adverse feeding-related health outcomes for their infants. Twenty-seven mothers participated in private, semi-structured interviews. Inductive and deductive qualitative content analysis revealed three primary themes of maternal perceived threats: a) choking, b) allergic reaction, and c) pickiness. Within each primary theme were sub-themes that further delineated the perceived threats and outlined specific and focused complementary feeding practices (CFPs) mothers used for each type of perceived threat. Findings suggest mothers have difficulty with estimating the likelihood and severity of risks and rely on elevated threat perception to guide their feeding decisions. CFPs used to prevent perceived threats were disproportionate to risks, and, at times, actually introduced additional, alternative risks.

Fathers' role in sustainability of exclusive breastfeeding practice in post-cesarean-section mothers

Background: The success of breastfeeding among post-cesarean- section mothers requires strong willingness and commitment, self-confidence, support from various professionals, and internal support (especially from their husband) and the belief and value of their family. Exclusive breastfeeding remains low in some cities such as in West Java, especially in post-cesarean-section mothers, who are influenced by certain factors. The purpose of this study is to identify husbands’ role and their support for post-cesarean-section mothers in exclusive breastfeeding.

Design and Methods: This study used a qualitative phenomenological approach. with a combination of different data collection techniques: focus group discussion and in-depth interviews. Twelve husbands of post-cesarean-section mothers participated in this study. Data were analyzed by thematic content analysis.

Results: Four themes were identified namely knowledge about exclusive breastfeeding, the role of the father during breastfeeding, the experience of the husband and the family in supporting breastfeeding, and Women’s lack of knowledge, inconvenience due to pain as the most impending factors of exclusive breastfeeding.

Conclusion: Most fathers seem eager to be involved and assist their partners to give breastfeeding to their baby. Furthermore, adequate support from family members, health care professionals, and employers can enable fathers to encourage and help their partners initiate and maintain exclusive breastfeeding. Fathers’ emotional, practical, and physical supports are also important factors that promote successful breastfeeding and enrich the experience of mothers.

Trends in breastfeeding practices and mothers' experience in the French NutriNet-Santé cohort

Background

France has one of the lowest rates in the world regarding breastfeeding initiation and duration. Few studies have explored breastfeeding practices in France since the middle of the twentieth century, or following from initiation to cessation. The purpose of our study was to determine trends in breastfeeding over the past decades regarding public health recommendations, and to examine mothers’ perceptions about factors known to have an impact on breastfeeding support and cessation.

Methods

From the NutriNet-Santé cohort, 29,953 parous women (launched in 2009 to study relation between nutrition and health), were included in the present study. Using web-questionnaires, they were asked retrospectively if they had breastfed their youngest child or not, and if so, the duration of exclusive and total breastfeeding. For those who had breastfed, we investigated their perceptions about support at initiation and during the entire breastfeeding period and reasons for breastfeeding cessation. We also asked those who did not breastfeed about their perceptions and reasons for infant formula feeding their youngest child. Analyses were weighted according to the French census data.

Results

In the NutriNet-Santé cohort, 67.3% of mothers breastfed their youngest child. The proportion of breastfed children increased over the past few decades, from 55.0% (95% CI 54.3, 55.6) in the 1970s to 82.9% (82.4, 83.4) in the 2010s. Total and exclusive breastfeeding duration went from 3.3 months and 2.4 months respectively in the 1970s to 5.9 months and 3.2 months respectively in the 2010s. Most mothers felt supported at initiation and during the breastfeeding period. A reported desire to have breastfed longer than two months was 59.5%. Mothers who did not breastfeed did it by choice (64.3%). They did not feel guilty (78.2%) and did not perceive a problem not to breastfeed (58.8%), but almost half of them would have liked to have breastfed (45.9%).

Conclusion

Breastfeeding duration has increased in the past decades but did not reach the public health recommendations threshold. Targets other than mothers have to be considered for breastfeeding education, like the partner and her environment, to increase breastfeeding practices.

Trial registration

The study was registered at ClinicalTrials.gov (NCT03335644).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00397-x.

Determinants of Non-paid Task Division in Gay-, Lesbian-, and Heterosexual-Parent Families With Infants Conceived Using Artificial Reproductive Techniques

Background: The division of non-paid labor in heterosexual parents in the West is usually still gender-based, with mothers taking on the majority of direct caregiving responsibilities. However, in same-sex couples, gender cannot be the deciding factor. Inspired by Feinberg’s ecological model of co-parenting, this study investigated whether infant temperament, parent factors (biological relatedness to child, psychological adjustment, parenting stress, and work status), and partner relationship quality explained how first-time gay, lesbian, and heterosexual parents divided labor (childcare and family decision-making) when their infants were 4 and 12 months old. We also tested whether family type acted as a moderator.

Method: Participants were drawn from the new parents study. Only those who provided information about their biological relatedness to their child (N = 263 parents) were included. When infants were 4 months (T1), parents completed a password-protected online questionnaire exploring their demographic characteristics including work status and standardized online-questionnaires on task division (childcare and family decision-making), infant temperament, parental anxiety, parental depression, parental stress, and partner relationship satisfaction. When infants were 12-months-old (T2), parents provided information about task division and their biological relatedness to their children.

Results: Linear mixed models showed that no factor explained the division of family decision making at T1 and T2. For relative time spent on childcare tasks at T1, biological relatedness mattered for lesbian mothers only: biologically related mothers appeared to spend more time on childcare tasks than did non-related mothers. Results showed that, regardless of family type, parents who were not working or were working part-time at T1 performed more childcare tasks at T1. This was still true at T2. The other factors did not significantly contribute to relative time spent on childcare tasks at T2.

Conclusion: We had the opportunity to analyze the division of non-paid tasks in families where parenting was necessarily planned and in which gender could not affect that division. Although Feinberg’s model of co-parenting suggests that various factors are related to task division, we found that paid work outside the home was most important during the first year of parenthood in determining caregiving roles.

Men's experience of first fatherhood discovery: a descriptive study based on free hierarchical evocation by associative networks

Objective and Background: Men's experiences of first-fatherhood discovery differ widely with various circumstances; they were examined according to the intended/unintended occurrence of partner's pregnancy.Methods: An Associative Network study targeted 44 first-time fathers and analysed their reactions to a stimulus-sentence 'In the first days after pregnancy announcement … 'Results: Word-associations formed 19 themes and 5 metathemes. The main metathemes were Emotional (30%), Cognitive (27%) and Relational (23%). Negative emotions were more frequent in unintended vs. intended pregnancies. Subthemes Chock, Feeling of unreality, Emotion control, Guilt, Denial, or Regret prevailed in unintended pregnancies. The major theme in all pregnancies was Personal advancement but subthemes Physical and psychological preparation and Responsibility prevailed in intended pregnancies vs. Acceptation and Personal progress in unintended pregnancies. Themes Relationships (with partner and others) were more frequently mentioned in unintended pregnancies vs. theme Logistics in intended pregnancies. Overall, the participants expressed opposed conflicting emotions but a desire for real involvement in pregnancy, birth, and child-raising.Conclusion: The participants proved interested and concerned. Fathers's presence and support should be solicited, accounted for, and valued by mothers-to-be and health professionals in all pregnancies. Involving fathers since pregnancy is essential for mental equilibrium, child-parent attachment, child and parent development, and family relationships.

A systematic review and meta-analysis of interventions incorporating behaviour change techniques to promote breastfeeding among postpartum women

The benefits of exclusive breastfeeding are well documented, yet few women adhere to recommendations. We report the Behaviour Change Techniques (BCTs) within interventions trialled internationally after pregnancy to promote exclusive and mixed breastfeeding as well as evidence of effectiveness. PsycINFO, EMBASE and MEDLINE databases were screened. Twenty-three (n = 23) studies met inclusion criteria. Three authors independently extracted data, coded interventions using the BCT v.1 taxonomy, and assessed study quality. There was a moderate significant effect of the interventions promoting exclusive breastfeeding up to four weeks postpartum (OR 1.77, [95% CI: 1.47-2.13]) but this effect slightly declined beyond thirteen weeks (OR 1.63, [95% CI: 1.07-2.47]). Twenty-nine BCTs were identified within interventions. 'Credible source' and 'instruction on how to perform the behaviour' were the most prevalent and 'social support (unspecified)' contributed to the effectiveness of exclusive breastfeeding interventions five to eight weeks postpartum. Using BCTs with cognitive and behavioural aspects may help women develop coping mechanisms promoting exclusive breastfeeding. Further trials are needed in countries with low breastfeeding rates such as the UK. The use of programme theory during intervention development and clear description of intervention components is recommended. This meta-analysis provides guidance for trials evaluating postpartum breastfeeding interventions.

Husbands' participation in prenatal care and breastfeeding self-efficacy in Iranian women: A randomized clinical trial

Background: Self-efficacy is an important psychological and motivational factor for continuation of exclusive breastfeeding. This study aimed to examine the effect of husband participation on self-efficacy of breastfeeding in postpartum period. Methods: This study was a single-blind clinical trial (IRCT2014012115163N2) conducted on 66 pregnant women who referred to health centers of Urmia in 2014. Convenience sampling method was used to select the participants and then they were randomly allocated to control and intervention groups using RANDBETWEEN function in Excel. Participants in the intervention group had 2 training sessions with 4-week interval. They could also use telephone counseling over study time. Those in the control group received the routine pregnancy care, and their breastfeeding self-efficacy was compared 1 month after delivery using Dennis Breastfeeding Self-Efficacy questionnaire. The data were analyzed using SPSS version 20. Chi square, independent and paired samples t test were used. Results: In this study, the mean score of breastfeeding self-efficacy in the intervention and control groups after intervention was 50.36±8.65 and 44.12±10.41, respectively, which showed a statistically significant difference (p=0.017). Conclusion: According to the results, one of the considerable strategies to enhance self-efficacy of breastfeeding is to involve husbands in prenatal care, which should be considered by the authorities and health professionals, including doctors, nurses, and midwives.

A qualitative study to explore fathers' attitudes towards breastfeeding in South West England

Aim

To explore the beliefs, attitudes, and behaviours of fathers towards breastfeeding and how they impact either positively or negatively on their partners’ decisions to initiate or continue breastfeeding.

Background

Despite policy initiatives at a national and international level and the increased number of baby-friendly hospitals within the UK, breastfeeding rates are slow to rise. Support from both parents has been proven to increase uptake and continuation rates, but there is little research into the emotional experience of fathers when it comes to breastfeeding.

Methods

We conducted qualitative interviews with 18 fathers in Wiltshire, England. Principles of grounded theory were used throughout this study to guide the sampling, data collection, and data analysis.

Findings

Fathers knew the health benefits of breastfeeding and wanted their child to breastfeed but were unsure of their place in the feeding process because they felt it was not their body. While they were aware of the benefits of breast milk for infants, fathers felt less informed of the practicalities of breastfeeding and the potential challenges they and their partner might have to overcome to breastfeed successfully for the recommended six-month period. Based on these findings, three segments were identified: the problem bonders, the dual bonders, and the pragmatists. All segments were concerned with the well-being of their partner and child and wanted their child to be breastfed. Health professionals can use the results of this study to create prenatal educational resources that take more of a preventive and problem-solving approach as opposed to promoting breastfeeding in efforts to comply with National Health Service guidelines, without offering solutions to common breastfeeding problems.

Men's views and experiences of infant feeding: A qualitative systematic review

Although the advantages of breastfeeding are well documented, rates for breastfeeding often fall short of international and national targets. Increasing attention has been paid to the role of men in infant feeding, but a lot of the research about men has been elicited from women, rather than from men themselves. To explore these issues further, a systematic review of the qualitative research on infant feeding was carried out, focusing specifically on men's own views and experiences. Evidence was identified by searching electronic databases (CINAL, Cochrane, PubMed, and Scopus), manually searching citations, and by searching the grey literature. Studies were included in the review if they discussed men's views and experiences of infant feeding and if they reported primary qualitative data. Twenty research papers were included in the review, and each study was summarised and then analysed thematically to produce a synthesis. Five major analytical themes were identified: men's knowledge of infant feeding; men's perceptions of their role in infant feeding; positive views on breastfeeding; negative views on breastfeeding; and men's experiences of health promotion and support. The review concludes by highlighting that although men can play an important role in supporting women, they do not have a significant role in infant feeding decisions.

Dojenje in tandemsko dojenje

Uvod: Tandemsko dojenje ali dojenje sorojencev je slabo poznan koncept. Matere, ki tandemsko dojijo, se srečujejo s socialno stigmo in slabo oporo s strani zdravstvenih strokovnjakov. Namen raziskave je bil proučiti znanje o  tandemskem dojenju med študenti zdravstvenih ved.Metode: Uporabljen je bil kvantitativni eksplorativni neeksperimentalni raziskovalni dizajn. V priložnostni vzorec so bili vključeni študenti zdravstvene nege (n = 66) in dietetike (n = 24). Podatki so bili zbrani s strukturiranim vprašalnikom (Cronbach α = 0,914). Uporabljena je bila opisna statistika, test hi-kvadrat in analiza variance.Rezultati: Da je popolnoma fiziološko, da ženska prekine dojenje starejšega otroka, če rodi naslednjega otroka, meni 50,7 % (n = 36) žensk in 84,2 % (n = 16) moških (χ2 = 6,898, p = 0,009). Kaj je izključno dojenje v prvih šestih mesecih, ve 79,2 % (n = 19) študentov dietetike in le 54,5 % (n = 36) študentov zdravstvene nege (χ2 = 4,489, p = 0,034). Nepravilnost trditve, da dojenčki v primeru tandemskega dojenja težje pridobivajo telesno težo, je prepoznalo 86,3 % (n = 44) žensk in 13,7 % (n = 7) moških.Diskusija in zaključek: V raziskavo vključeni študentje so izkazali pomanjkljivo znanje tako o dojenju na splošno kakor tudi o tandemskem dojenju. V študijski program bi bilo treba vnesti več vsebin o dojenju.

The emotional and practical experiences of formula-feeding mothers

The majority of infant-feeding research is focused on identifying mother's reasons for the cessation of breastfeeding. The experience of mothers who choose to use formula is largely overlooked in quantitative designs. This study aimed to describe the emotional and practical experiences of mothers who formula feed in any quantity, and examine whether these experiences would vary among different cohorts of formula-feeding mothers according to prenatal feeding intention and postnatal feeding method. A total of 890 mothers of infants up to 26 weeks of age, who were currently formula feeding in any quantity, were recruited through relevant international social media sites via advertisements providing a link to an online survey. Predictors of emotional experiences included guilt, stigma, satisfaction, and defense as a result of their infant feeding choices. Practical predictor variables included support received from health professionals, respect displayed by their everyday environment, and main sources of infant feeding information. Descriptive findings from the overall sample highlighted a worryingly high percentage of mother's experienced negative emotions as a result of their decision to use formula. Multinomial logit models revealed that negative emotions such as guilt, dissatisfaction, and stigma were directly associated with feeding intention and method. The evidence suggests that the current approach to infant-feeding promotion and support may be paradoxically related to significant issues with emotional well-being. These findings support criticisms of how infant-feeding recommendations are framed by health care professionals and policy makers, and highlight a need to address formula feeding in a more balanced, woman-centered manner.

'Both parents should care for babies': A cross-sectional, cross-cultural comparison of adolescents' breastfeeding intentions, and the influence of shared-parenting beliefs

BACKGROUND

Many young men and women expect to co-parent their newborn infant. This may have a positive or negative impact on decisions to breastfeed, which is an important health behaviour, influenced by cultural and psycho-social norms. We investigated the relationship between shared parenting, infant feeding beliefs and intentions in male and female (non-parent) adolescents, comparing Nordic countries (Sweden, Norway, Finland) with high breastfeeding rates with others with low rates (Scotland, USA).

METHODS

We utilised cross-sectional surveys of male and female adolescents (n = 1064, age 12-18) administered directly in schools or via the internet. We assessed attitudes to breast and formula feeding and shared parenting, using a Theory of Planned Behaviour framework, assessing beliefs, attitudes, norms and control as predictors of intention.

RESULTS

Male and female adolescents' breastfeeding intentions varied in line with national cultural norms. Young people from Nordic countries (high breastfeeding rates) were significantly more likely to intend to breastfeed than those from Scotland or the USA (low breastfeeding rates). Positive beliefs about breastfeeding, norms and 'exposure' to breastfeeding and feeding confidence were consistently stronger in Nordic countries, whereas young people in Scotland had more positive beliefs, norms and 'exposure' to formula feeding. Differences in parenting beliefs, norms and confidence were less consistent. In logistic regression, cultural group, positive breastfeeding beliefs and exposure, norms, and shared parenting beliefs were significant predictors of breastfeeding feeding intention.

CONCLUSIONS

Positive beliefs about shared parenting and equal gender norms were related to future breastfeeding intentions for female and male adolescents. Health education programmes for young people could encourage positive breastfeeding choices by considering how this would fit with young people's ideal parenting roles, and by emphasising benefits of complementary maternal and paternal roles in breastfeeding newborn infants.

Connections Between Prenatal Physical Activity and Breastfeeding Decisions

Women who engage in prenatal physical activity give themselves, and their child, an advantage over women who did not engage in prenatal physical activity; not only are there significant health benefits for mothers, but there are also great benefits for the unborn child. Breastfeeding is another important decision parents make that can affect the mother and her child. There has been extensive research on the benefits of both prenatal physical activity and breastfeeding, but the connection between the two is unclear. The purpose of this grounded theory article was to identify potential connections between factors influencing women's decisions to engage in prenatal physical activity and breastfeeding among mothers in a medium-sized city in Tennessee. Responses from mothers revealed numerous themes related to both prenatal physical activity and breastfeeding. Connections between prenatal physical activity and breastfeeding, in addition to an overarching theme that captured the women's collective experience, were identified.

Stakeholder views of breastfeeding education in schools: a systematic mixed studies review of the literature

BACKGROUND

Breastfeeding provides numerous health benefits for mothers and infants, but worldwide breastfeeding rates fall below recommendations. As part of efforts to increase breastfeeding initiation and duration, the World Health Organization and UNICEF UK recommend educational interventions to increase awareness and positive attitudes towards breastfeeding beginning during the school years. Breastfeeding education in the school setting offers the opportunity to improve the knowledge base, address misconceptions, and positively influence beliefs and attitudes for students from a wide range of socioeconomic and cultural backgrounds. The purpose of this paper is to present a comprehensive narrative review of the literature regarding student and teacher (stakeholder) views of breastfeeding and breastfeeding education programs in schools to inform future research in the area.

METHODS

Articles were located through a systematic search of online databases and journals using the following keywords in various combinations: (1) breastfeeding, lactation, breast-feeding, "bottle feeding", "infant feeding" (2) student, educator, teacher, "school administrator" and (3) schools, "secondary education", "primary education", "K-12", "high school", "middle school", "elementary school", education, adolescents, curriculum, and a manual search of article references. Studies were screened for inclusion against specific criteria and included papers were assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

This review suggests that adolescents have a deficit in breastfeeding knowledge and express negative conceptions about breastfeeding. Breastfeeding is being discussed in some school environments, but the extent of lessons and the specific messages that teachers communicate have not been explored. Students appear to be interested in receiving more information about breastfeeding, especially if delivered by health professionals or breastfeeding mothers. The majority of teachers are supportive of incorporating breastfeeding education in family and consumer sciences, sexual education, and health classes; however, time constraints and limited knowledge of infant feeding recommendations may be barriers to implementation of appropriate lesson plans.

CONCLUSIONS

Students generally support and are receptive to breastfeeding education; however, research on educator attitudes, knowledge, and experiences are necessary for appropriate implementation of breastfeeding education in varying school settings around the world.

Breast-feeding Coparenting Framework: A New Framework to Improve Breast-feeding Duration and Exclusivity

Targeting mothers and fathers in breast-feeding promotion programs is recommended as research has found that father's support positively impacts breast-feeding duration and exclusivity. Breast-feeding coparenting refers to the manner in which parents work together to achieve their breast-feeding goals. The Breast-feeding Coparenting Framework was developed on the basis of diverse coparenting models and research related to father's involvement with breast-feeding. This framework consists of 5 components: joint breast-feeding goal setting, shared breast-feeding responsibility, proactive breast-feeding support, father's/partner's parental-child interactions, and productive communication and problem solving. This framework may be of value to policy makers and program providers working to improve breast-feeding outcomes.

Access, Use, and Preferences for Technology-Based Perinatal and Breastfeeding Support Among Childbearing Women

We surveyed 146 postpartum women who birthed at 34-37 6/7 weeks of gestation and intended to breastfeed about their use of and preferences regarding technology to obtain perinatal and breastfeeding support. Most participants owned smartphones and used technology during pregnancy to track pregnancy data, follow fetal development, address pregnancy concerns, and obtain breastfeeding information. Internet, e-mail, apps, and multiplatform resources were the most popular technologies used and preferred. Demographic differences existed in mobile technology access and preferences for different technologies. In terms of technology-based breastfeeding support, women wanted encouragement, anticipatory guidance, and information about milk production. A nuanced understanding of the technology childbearing women use and desire has the potential to impact clinical care and inform perinatal support interventions.

Artificial milk-feeding women׳s views of their feeding choice in Ireland

OBJECTIVE

despite the well-documented benefits of breast feeding to both mother and child, breast-feeding initiation rates in Ireland are the second lowest in Europe. This study set out to explore the views of women from low socio-economic groups in Ireland on their choice to feed their infants artificial milk, and to elicit factors that may encourage these women to breast feed in the future.

DESIGN

a qualitative descriptive approach was used.

METHODS

data were collected through recorded focus groups and individual interviews, using a semi-structured interview schedule. Data were transcribed verbatim.

SETTING

interviews took place in two regions in the Republic of Ireland, north and south.

PARTICIPANTS

a purposive sample was drawn from the population of 2572 women taking part in the Irish Infant Feeding Study who had never breast fed previously, had intended to, and had, fed this infant artificial milk and who had completed their education before they were 18 years of age. Two focus groups with two women in each were conducted and six women took part in individual interviews.

ANALYSIS

constant comparative analysis was performed to construct the categories and concepts that led to the final themes.

FINDINGS

these artificial milk-feeding women based their infant feeding decision on many social and experiential factors. The major influences on their decisions were: personal attitudes toward feeding methods, and external influences on infant feeding methods. Attitudes towards other women and feeding future infants reinforced a strong preference towards artificial milk feeding.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

it is apparent that a prevailing culture that is unreceptive to breast feeding and the lack of positive breast-feeding role models, contributed to a strong commitment to artificial milk feeding for these participants. Promotion of breast feeding must take account of the complex contexts in which women make decisions. Advice regarding breast feeding should take account of women׳s feelings and avoid undue pressure, while still promoting the benefits of breast feeding to women and their families.

When 'breast' is no longer 'best': Post-partum constructions of infant-feeding in the hospital

In this paper, we focus on the initial experiences of breastfeeding among mothers to examine the ways that infant-feeding is socially constructed in the hospital. Data comes from 51 in-depth interviews with 17 first-time mothers in Ontario, Canada. Analysis reveals 52 magnified moments that we categorize as Successful, Ultimately Successful and Unsuccessful. For mothers who describe Successful and Ultimately Successful moments, breastfeeding is understood as physiologically natural, and as something they must learn to do. Unsuccessful moments reveal that when health care providers interpret breastfeeding as not working, the breastfeeding discourse frequently shifts to one that incorporates formula as the means to achieve optimal infant health. In other words, in the hospital 'breast is best' holds true when breast 'works', otherwise mothers are often directed to give their babies formula. While formula appears to be compulsory in these moments, it is not typically understood as a "good or best" infant-feeding practice. For mothers in this situation, the shift from breast to formula is experienced as failures or evidence of inadequacy in their mothering. Paradoxically, our results suggest that formula may not, in and of itself, pose a threat to mothers' overall continued practice of breastfeeding. It appears that Successful and Ultimately Successful moments coincide with the current dominant 'breast is best' understanding. Unsuccessful moments, conversely, are insightful because they reveal when and how hospital practices disrupt mothers' understanding of their bodies and their role in providing the 'best' form of infant food. The implications for policy and practice are discussed.

Expressionists of the twenty-first century: the commodification and commercialization of expressed breast milk

Breast milk expression has been promoted as liberating for women and as offering them more choices, but there has been little research on women's experiences of it and even less critical commentary on the consequences of its incorporation into mainstream behavior. Drawing on narratives of women in the United Kingdom about breastfeeding, we explore the increasingly popular practice of expressing and feeding expressed breast milk. We argue that breast milk has become commodified, breastfeeding commercialized and technologized, and the mother-infant relationship disrupted. We suggest that breastfeeding as a process is being undermined by vested interests that portray it as unreliable and reconstruct it in artificial feeding terms, so playing on women's insecurities. The major beneficiaries of expression are fathers who want increased involvement in infant care and commercial enterprises that aim to maximize profits for shareholders.

Characteristics of breastfeeding discussions at the initial prenatal visit

OBJECTIVE

To describe the observed characteristics of first prenatal visit breastfeeding discussions between obstetric providers and their pregnant patients.

METHODS

This analysis was part of a larger study involving 69 health care providers and 377 patients attending their initial prenatal visits at a single clinic. Audio recordings and transcripts from the first 172 visits (including 36 obstetric-gynecology residents, six nurse midwives, and five nurse practitioners) were reviewed for breastfeeding discussion occurrence, timing and initiator of discussions, and adherence to American College of Obstetricians and Gynecologists (College) prenatal breastfeeding guidelines. Descriptive statistics were used to characterize the sample and frequency of breastfeeding discussions. Logistic regression and χ tests were used to examine patterns in women's breastfeeding discussion preferences and discussion occurrence. Conversations were qualitatively analyzed for breastfeeding content.

RESULTS

Breastfeeding discussions were infrequent (29% of visits), brief (mean 39 seconds), and most often initiated by clinicians in an ambivalent manner. Sixty-nine percent of breastfeeding discussions incorporated any College breastfeeding recommendations. Breastfeeding was significantly more likely to be discussed by certified nurse midwives than residents (odds ratio 24.54, 95% confidence interval 3.78-159.06; P<.01), and certified nurse midwives tended to engage patients in more open discussions. Women indicating a preference for breastfeeding discussions at the first visit (n=19) were more likely to actually have the discussion (P<.001).

CONCLUSION

Observed breastfeeding education at the first prenatal visit was suboptimal. The causes and effect of this deficiency on breastfeeding outcomes remains an important point of investigation.

LEVEL OF EVIDENCE

: II.

Is paternal infant care associated with breastfeeding? A population-based study in Japan

BACKGROUND

One qualitative study has reported that more paternal infant care and housework contributed to the maintenance of breastfeeding. However, few studies have quantitatively investigated these relationships.

OBJECTIVE

This study aimed to examine the association of paternal involvement in infant care and housework with exclusive breastfeeding during the first 6 months of life.

METHODS

Data from a population-based birth cohort study in Japan, the Longitudinal Survey of Babies in the 21st Century, were analyzed. We extracted information on infants who were singletons, term, normal birth weight, and living with both parents (n = 39 742). The associations between degree of paternal involvement in infant care and housework (high, middle, low) and breastfeeding patterns (exclusive, partial, formula only) were analyzed using ordered logistic regression adjusted for covariates. Maternal anxiety about childrearing was considered as a mediator.

RESULTS

Compared with the low level of paternal infant care group, infants in the middle and high level groups were significantly less likely to have been breastfed (adjusted odds ratio: 0.90, 95% confidence interval [CI], 0.84-0.97; and 0.73, 95% CI, 0.67-0.79, respectively). In contrast, the amount of housework carried out by fathers was not associated with breastfeeding pattern. Maternal anxiety about childrearing did not attenuate the association between paternal infant care and breastfeeding.

CONCLUSION

Paternal infant care was inversely associated with breastfeeding during the first 6 months of life. An additional intervention study about the importance of breastfeeding that aims to educate fathers who tend to involve themselves in infant care is needed.

Promoting positive attitudes to breastfeeding: the development and evaluation of a theory-based intervention with school children involving a cluster randomised controlled trial

The objective of this study was to design, implement and evaluate an intervention based on the theory of planned behaviour (TPB) to enhance young peoples' motivations to breastfeed/support a partner to breastfeed. Six semi-structured focus groups were first conducted with 48 13-14-year-olds from two schools in Northern Ireland. The salient beliefs elicited were subsequently used to design a TPB-based questionnaire that was then administered to 2021 13-14-year-old pupils (852 males; 1169 females) from 36 post-primary schools to identify the most important determinants of breastfeeding. The results were used to inform the design and implementation of an intervention package that was subsequently evaluated using a cluster randomised controlled trial involving 44 randomly selected schools across Northern Ireland. Questionnaires were administered to 18 intervention and 26 control schools at baseline and again at 1 and 6 months post-intervention to evaluate its effectiveness. Multi-level modelling was employed to analyse the data. The results revealed significant effects on women's intention to breastfeed, β = 0.208, t(1275) = 2.715, P = 0.007; attitudes, β = 0.223, t(1275) = 4.655, P < 0.001; moral attitudes, β = 0.231, t(1275) = 4.211, P < 0.001; subjective norm, β = 0.118, t(1275) = 2.521, P = 0.012; and knowledge, β = 0.109, d.f. (1275) = 7.843, P < 0.001. However, for men, the results revealed significant effects on only the construct of knowledge, β = 0.104, t(541) = 4.345, P < 0.001.The research has provided evidence to support the need for breastfeeding education in schools and has shown how a theoretical framework may be used to inform the design and evaluation of a health behaviour intervention.

Engaging and supporting fathers to promote breast feeding: a concept analysis

OBJECTIVE

Empirical evidence demonstrates that fathers have a strong influence on a mother's decision to initiate and continue breast feeding. However, no clear delineation of what behaviours and attributes constitute father support or differentiate it from other kinds of support is provided in the current literature. The purpose of this study was to analyse the concept of 'father support' in relation to maternity services and broader health settings, thereby clarifying meaning to enable comprehension and application in practice, education, and research.

DESIGN

A concept analysis combining the evolutionary model of concept development with the inter-related theoretical, fieldwork and analytical phases of the hybrid model of concept development.

SETTING

Children's Centres in East and West Sussex in Southern England.

PARTICIPANTS

Repeated qualitative research over two phases with 16 parents of breast fed infants through seven focus groups and five telephone interviews.

MEASUREMENTS AND FINDINGS

CINAHL, PsycINFO, AMED, MEDLINE, OVID and EMBASE databases were searched for articles published in English between 1999 and 2013 using the keywords breast feeding, father, and support. Seven same-sex focus groups and five individual interviews were also conducted over two research phases with the parents of breast fed infants to expand and exemplify, and then validate the analysis of the literature search. Five main attributes of father support in relation to breast feeding were identified: (1) knowledge about breast feeding; (2) positive attitude to breast feeding; (3) involvement in the decision-making process; (4) practical support; and (5) emotional support. Multiple antecedents and consequences to these attributes were also identified.

KEY CONCLUSION

This study has contributed to clarifying the meaning of father support in relation to breast feeding and provides an important starting point for the development of a theoretical and practical model of optimal breast feeding that takes into account father support.

IMPLICATIONS FOR PRACTICE

Identification of attributes, antecedents, and consequences of father support may assist practitioners to reflect on current working practices and service delivery models, and offer important educational opportunities for the training of student midwives and other health professionals.

A qualitative study exploring factors associated with mothers' decisions to formula-feed their infants in Newfoundland and Labrador, Canada

BACKGROUND

Breastfeeding has numerous health benefits. In 2010, the province of Newfoundland and Labrador had the lowest breastfeeding initiation rate (64.0%) in Canada. Formula feeding is associated with well-known health risks. Exclusive formula feeding is the "cultural norm" in some regions of the province. Women appear resistant to changing their infant feeding behaviors and remain committed to their decision to formula-feed. The primary aim of this qualitative study was to examine individual factors that shaped mothers' decisions to formula-feed their infants. Nineteen mothers who were currently formula feeding their children participated in the study.

METHODS

Qualitative research in the form of focus groups was conducted in three communities in the province in 2010. A thematic content analysis identified the main themes that influenced mothers' decisions to formula-feed their infants.

RESULTS

The main themes included issues concerning the support needed to breastfeed, the convenience associated with formula feeding, and the embarrassment surrounding breastfeeding in public.

CONCLUSIONS

These findings help to better understand why mothers choose formula feeding over breastfeeding and may help to inform the development of public health interventions targeted at this population of mothers.

Exploring the process of women's infant feeding decisions in the early postbirth period

Research indicates that multiple factors are associated with decisions women make about infant feeding, yet few studies have explored the decision-making process. In this article, we present the analysis that produced the core category "deconstructing best," previously reported as part of a grounded theory exploring 37 Australian women's infant feeding experiences and decisions in the first 6 weeks postbirth. We expand on the previous article by detailing and discussing the phases of the infant feeding decision-making process in relation to decision-making theory. Analysis demonstrates the importance of these early weeks in shaping women's infant feeding trajectories. Findings illustrate that information gathering encompassing multiple factors occurred at this time, and that complex and often competing goals were involved in the women's decisions. We suggest that acknowledging and assisting women to meet alternate goals in the postbirth period might help them meet their breastfeeding goals.

Women's autonomy and husbands' involvement in maternal health care in Nepal

Both increasing women's autonomy and increasing husbands' involvement in maternal health care are promising strategies to enhance maternal health care utilization. However, these two may be at odds with each other insofar as autonomous women may not seek their husband's involvement, and involved husbands may limit women's autonomy. This study assessed the relationship between women's autonomy and husbands' involvement in maternal health care. Field work for this study was carried out during September-November 2011 in the Kailali district of Nepal. In-depth interviews and focus group discussions were used to investigate the extent of husbands' involvement in maternal health care. A survey was carried out among 341 randomly selected women who delivered a live baby within one year prior to the survey. The results show that husbands were involved in giving advice, supporting to reduce the household work burden, and making financial and transportation arrangements for the delivery. After adjustment for other covariates, economic autonomy was associated with lower likelihood of discussion with husband during pregnancy, while domestic decision-making autonomy was associated with both lower likelihood of discussion with husband during pregnancy and the husband's presence at antenatal care (ANC) visits. Movement autonomy was associated with lower likelihood of the husband's presence at ANC visits. Intra-spousal communication was associated with higher likelihood of discussing health with the husband during pregnancy, birth preparedness, and the husbands' presence at the health facility delivery. The magnitude and direction of association varied per autonomy dimension. These findings suggest that programs to improve the women's autonomy and at the same time increase the husband's involvement should be carefully planned. Despite the traditional cultural beliefs that go against the involvement of husbands, Nepalese husbands are increasingly entering into the area of maternal health which was traditionally considered 'women's business'.

Fathers' engagement in pregnancy and childbirth: evidence from a national survey

Background

Early involvement of fathers with their children has increased in recent times and this is associated with improved cognitive and socio-emotional development of children. Research in the area of father’s engagement with pregnancy and childbirth has mainly focused on white middle-class men and has been mostly qualitative in design. Thus, the aim of this study was to understand who was engaged during pregnancy and childbirth, in what way, and how paternal engagement may influence a woman’s uptake of services, her perceptions of care, and maternal outcomes.

Methods

This study involved secondary analysis of data on 4616 women collected in a 2010 national maternity survey of England asking about their experiences of maternity care, health and well-being up to three months after childbirth, and their partners’ engagement in pregnancy, labour and postnatally. Data were analysed using descriptive statistics, chi-square, binary logistic regression and generalised linear modelling.

Results

Over 80% of fathers were ‘pleased or ‘overjoyed’ in response to their partner’s pregnancy, over half were present for the pregnancy test, for one or more antenatal checks, and almost all were present for ultrasound examinations and for labour. Three-quarters of fathers took paternity leave and, during the postnatal period, most fathers helped with infant care. Paternal engagement was highest in partners of primiparous white women, those living in less deprived areas, and in those whose pregnancy was planned. Greater paternal engagement was positively associated with first contact with health professionals before 12 weeks gestation, having a dating scan, number of antenatal checks, offer and attendance at antenatal classes, and breastfeeding. Paternity leave was also strongly associated with maternal well-being at three months postpartum.

Conclusions

This study demonstrates the considerable sociodemographic variation in partner support and engagement. It is important that health professionals recognise that women in some sociodemographic groups may be less supported by their partner and more reliant on staff and that this may have implications for how women access care.

Evaluation of a theory of planned behaviour-based breastfeeding intervention in Northern Irish schools using a randomized cluster design

OBJECTIVE

The aim of this research was to evaluate the effectiveness of a school-based intervention designed to enhance young people's motivations to breastfeed.

DESIGN

A cluster randomized controlled trial was conducted involving 50 post-primary schools from across Northern Ireland. However, dropout and exclusion criteria utilized for the current study resulted in an effective sample size of 42 schools.

METHODS

The intervention was delivered in two 35-min classroom sessions targeting those beliefs identified by the theory of planned behaviour (TPB) as significant in predicting motivation to breastfeed. Questionnaires incorporating the key components of the TPB were administered to all intervention and control schools at baseline, 1 and 6 months post-intervention. Multi-level modelling was used to analyse the data.

RESULTS

Findings suggest that the intervention was effective in that it increased females' intentions to breastfeed, expanded their knowledge and led to more favourable attitudes and perceptions of subjective norms. Notably, females' knowledge increased more in secondary schools than in grammar schools irrespective of whether they were control or intervention schools.

CONCLUSION

The research has provided evidence to support the use of the TPB in the design and evaluation of an intervention to increase females' intentions to breastfeed.

Apoio paterno ao aleitamento materno: uma revisão integrativa

OBJETIVO: Identificar, na literatura científica, publicações sobre a participação do pai ou companheiro no aleitamento materno. FONTES DE DADOS: Realizou-se uma revisão integrativa no período de 1995 a 2010, utilizando-se os unitermos "pai" e "aleitamento materno" nas bases de dados LILACS, SciELO, BDENF e PubMed/MEDLINE. Os dados obtidos foram organizados em três categorias: o pai como suporte para a amamentação; percepções paternas sobre a amamentação; e o impacto da intervenção educativa sobre aleitamento para os pais. SÍNTESE DOS DADOS: Foram identificadas 44 publicações que mostraram que o apoio social, profissional e familiar foi imprescindível para o sucesso do aleitamento materno. O pai foi destacado como suporte fundamental pela forte influência na decisão da mulher em amamentar e na sua continuidade. Contudo, a participação do pai exibe sentimentos ambivalentes: competitividade com a mãe vs. proteção; exclusão vs. aumento do vínculo familiar; apoio vs. preconceitos. Os profissionais de saúde, apontados como referência na busca de informações, mostram-se despreparados para atender aos pais. CONCLUSÕES: Foram encontradas várias produções científicas ressaltando a relevância do apoio paterno para o sucesso do aleitamento materno. Contudo, a maioria das pesquisas apresenta abordagem descritiva, havendo poucos estudos com intervenções educativas.

How are babies fed? A pilot study exploring primary school children's perceptions of infant feeding

BACKGROUND

  Breastfeeding is the optimal feeding method for human infants. In the United Kingdom some women do not initiate breastfeeding, and many commence formula milk feeding after a brief period of breastfeeding. Infant feeding perceptions may develop early in life, and this research aimed to explore infant feeding awareness among primary school children as a first step toward informing appropriate health education interventions.

METHOD

  Fifty-six children aged 5/6, 7/8, and 10/11 years were recruited from three schools in southern England. Children were shown a series of drawings, and were read a story about a hungry newborn baby. A creative method, "draw, write and tell," was developed for this research. Children were asked to finish the story, showing how they thought the baby might be fed. They were given the opportunity to verbally interpret their work. A constant comparison method was used to analyze the data.

RESULTS

  Children were aware of formula milk, breastfeeding, and solid foods. Formula milk feeding was referred to more frequently than breastfeeding. Some children combined feeding methods. Children appeared to have gained their awareness in various settings.

CONCLUSIONS

  Children have a range of perceptions around infant feeding. They appear receptive to new ideas on the subject while of primary school age. An opportunity for education in primary schools arises to present breastfeeding to children as a normal way to feed a baby, but it is vital that education is evidence based and any interventions are evaluated.

Expectant fathers' and mothers' perceptions of breastfeeding and formula feeding: a focus group study in three US cities

The objective of the current study was to better understand how pregnant women and male partners conceptualize infant feeding and support for breastfeeding. Information was collected through 18 focus group interviews in 3 major US cities. There were 121 focus group participants of varying professions and income levels. Half were African American and half were Caucasian. Pregnant women and male partners had favorable attitudes toward breastfeeding, but did not articulate specific benefits to mothers or infants. Men expressed empathy for their partners' pregnancies and deferred to their partners' feeding decisions. Both groups disapproved of breastfeeding in public. Women voiced concerns about father-infant bonding more than men did. Both groups emphasized fathers' support of the infant, but not of the mother. Educators and practitioners may wish to consider expectant couples' perceptions of breastfeeding in public, knowledge of breastfeeding laws, and expectations of father-mother and father-infant relationships in their approach to breastfeeding promotion among expectant couples.

'She can choose, as long as I'm happy with it': a qualitative study of expectant fathers' views of birth place

OBJECTIVES

A programme of research was undertaken to explore which factors contributed to decisions regarding birth place. As part of this programme, the views of male partners of pregnant women were examined to gain understanding of their contribution to the decision making process, with regard to different birth settings.

STUDY DESIGN

A qualitative interpretive approach was utilised to explore, in-depth, the views of 19 expectant fathers, in the North West of England. Semi-structured interviews were conducted, audio recorded and transcribed, following consent. Data were analysed using a thematic approach.

FINDINGS

Four main themes were identified; Silent decisions, Powers of persuasion, Trust in a medical environment and Personal vulnerability.

CONCLUSIONS

Choice regarding place of birth is multi-dimensional. Expectant fathers are likely to contribute to their partner's decision making; their motivation can relate to their own beliefs and personal vulnerability as well the need to protect the women. The overwhelming trust in the medical environment dominates partner's views regarding birth place. The lack of discussion regarding birth place, between partners and with health professionals, reinforces the notion that hospital birth is safest, thus strengthening the normalization of birth in this environment. Midwives need to engage with expectant fathers to ensure that their contributions to decisions around birth place are fully informed.

Breastfeeding support - the importance of self-efficacy for low-income women

Breastfeeding is a key determinant in promoting public health and reducing health inequality. Low-income women have a significantly lower level of breastfeeding. Midwives in the UK have been encouraged to implement the World Health Organization/United Nations Children's Fund's Ten Steps to Successful Breastfeeding, but to date, there has been no evaluation of the impact of the training initiative on the breastfeeding behaviours of low-income women. As part of a wider study, this qualitative component was designed to answer the question - what are the views and experiences of low-income women (defined by Jarman scores) in relation to their breastfeeding support received in the post-natal period? A sample of seven women was interviewed. The in-depth interviews were analysed using a qualitative, thematic approach based on the self-efficacy theory. The four themes that emerged from the data were the following: breastfeeding related to the woman's self-confidence, the social environment in which the woman lived, knowledge of breastfeeding and the influence of maternity services on breastfeeding outcomes. These themes were interpreted in relation to the self-efficacy theory. The findings suggest that the components that inform self-efficacy are consistent with the themes from the data, suggesting that midwives and other health professionals should take the psychosocial aspects of breastfeeding support into account. As this important feature of breastfeeding support is not explicitly part of the current Ten Steps to Successful Breastfeeding, we suggest that further research and debate could inform expansion of these minimum standards to include the psychosocial aspects.

A meta-ethnographic synthesis of women's experience of breastfeeding

Despite considerable evidence and effort, breastfeeding duration rates in resource-rich countries such as Australia remain below World Health Organization recommendations. The literature on the experience of breastfeeding indicates that women construct and experience breastfeeding differently depending upon their own personal circumstances and the culture within which they live. Breastfeeding has also been described as a deeply personal experience, which can be associated with 'moral' decision-making. The aim of this synthesis was to better understand the social phenomenon of breastfeeding by making the hidden obvious. Using a meta-ethnographic approach, we analysed the findings from 17 qualitative studies exploring women's experience of breastfeeding. Commonly used metaphors, ideas and phrases across the national and international qualitative studies were identified. Two overarching themes emerged. Breastfeeding was described in terms of 'expectation' and 'reality', while the emotional aspects of breastfeeding were expressed in 'connected' or 'disconnected' terms. The prevalence of health professionals and public health discourses in the language women use to describe their experience, and the subsequent impact of this on maternal confidence and self-assessment of breastfeeding are discussed. This synthesis provides insight into some of the subtle ways health professionals can build maternal confidence and improve the experience of early mothering.

The influence of the "they": an interpretation of breastfeeding culture in New Zealand

The society in which a woman breastfeeds has a significant effect on how she will interpret her breastfeeding experiences; however, only limited research has been conducted on the phenomenon of breastfeeding, despite the recognition that the majority of women do not breastfeed beyond 6 months. In this article I present the findings of a research study that explored the experience of breastfeeding for 19 women in New Zealand using an interpretive lifeworld methodology. The participants engaged in interviews about their experience of breastfeeding. The interviews were analyzed alongside Heidegger's exposition of the "they" as a dialogical partner. The findings are presented in themes that articulate how women experience societal culture when breastfeeding, and how this culture influences their interpretations of their breastfeeding experiences. This research contributes to expanding understandings about why women might wean their infants prematurely, and provides insights into how health care professionals might support women to prolong breastfeeding.

Reproductive-aged women's knowledge and attitudes regarding infant-feeding practices: an experimental evaluation

Using an experimental design, this study assessed knowledge, attitudes, and intentions regarding infant feeding practices among Canadian female university undergraduates (N = 285). Participants completed a survey of knowledge, attitudes, and intentions with respect to infant-feeding practices. Two versions of the survey were randomly distributed to participants: one containing a photograph of a woman breastfeeding her infant (n = 131) and the other containing a photograph of the same women bottle-feeding her infant (n = 154). Findings indicated that the majority of the sample had been breastfed (84%) and intend to breastfeed their own offspring (97%). The intention to breastfeed future offspring was predicted by knowledge, attitudes, and perceptions of social norms. Participants reported more positive attitudes toward visual depictions of breastfeeding compared with bottle-feeding but less positive views of breastfeeding in public compared with bottle-feeding in public. Participants also significantly underestimated the health benefits and optimal duration of breastfeeding. The findings highlight gaps in knowledge that may contribute to premature cessation of breastfeeding among Canadian women and suggest the need for breastfeeding education.

Mothers' experiences of bottle-feeding: a systematic review of qualitative and quantitative studies

OBJECTIVE

Most babies receive at least some formula milk. Variations in formula-feeding practices can have both short- and long-term health consequences. The literature on parents' experiences of bottle-feeding was systematically reviewed to understand how formula-feeding decisions are made.

METHODS

Relevant English-language papers, identified by searching 12 electronic databases, reference lists and related articles and by contacting first authors of included papers, were systematically searched for and appraised. The included studies were analysed and synthesised using a combination of narrative and thematic approaches. Consensus on the final inclusion, interpretation and synthesis of studies was reached across the research team.

RESULTS

Six qualitative studies and 17 quantitative studies (involving 13 263 participants) were included. Despite wide differences in study design, context, focus and quality, several consistent themes emerged. Mothers who bottle-fed their babies experienced negative emotions such as guilt, anger, worry, uncertainty and a sense of failure. Mothers reported receiving little information on bottle-feeding and did not feel empowered to make decisions. Mistakes in preparation of bottle-feeds were common. No studies examined how mothers made decisions about the frequency or quantity of bottle-feeds.

CONCLUSIONS

Inadequate information and support for mothers who decide to bottle-feed may put the health of their babies at risk. While it is important to promote breastfeeding, it is also necessary to ensure that the needs of bottle-feeding mothers are met.

A qualitative approach to social support and breast-feeding decisions

OBJECTIVE

to explore pregnant women's perceptions and personal experiences of the influence of formal and informal social support on breast-feeding decision-making, in relation to breast-feeding initiation and duration.

DESIGN

qualitative focus groups and interviews.

SETTING

four primary-care centres in Valencia, Spain.

PARTICIPANTS

19 primiparous women in their first trimester of pregnancy participated in focus groups and 12 primiparous and multiparous women in their third trimester of pregnancy participated in interviews. Women had different socio-demographic backgrounds and socio-economic status.

FINDINGS AND CONCLUSIONS

women's perceptions and personal experiences of formal and informal social support of breast feeding may be linked to age and socio-cultural status. Women from higher socio-cultural backgrounds took their partner's opinion and support more into account when choosing breast feeding. They also conceded great importance to formal health support, and employed mothers wished to have more institutional support. Among women from lower socio-cultural backgrounds, friends were the closest social network and had the greatest influence on feeding decisions. They perceived some contradictions in health-promotion messages on breast feeding, and most of them preferred to leave work after birth to exclusively care for their baby. Younger women, without previous experience of breast feeding or possibility of receiving tangible support from their mothers, wanted more practical health-care support (e.g. providing skills in breast-feeding technique).

IMPLICATIONS FOR PRACTICE

breast-feeding promotion strategies should take into account women's different characteristics. Health professionals should consider offering postnatal support as a follow-up to practical support (e.g. breast-feeding workshops).