Breastfeeding is a natural form of infant feeding, but not all women breastfeed, and those who do may not necessarily feed for the recommended length of time (Feenstra et al, 2018). It is advised that breastfeeding takes place exclusively for the first 6 months of an infant's life, followed by the introduction of nutritional foods alongside breastfeeding up to 2 years of age and beyond (World Health Organization (WHO), 2011). Breastfeeding an infant up to and over 8 months of age has been found to result in numerous physical health benefits, such as improved immunity through the transfer of antibodies; protection against health conditions such as diabetes, obesity and allergies (WHO and UNICEF, 2003); and increased cognitive advantages such as higher IQ scores (Horwood and Fergusson, 1998).
The low levels of breastfeeding observed within the UK and other western countries led to the development of the UNICEF Baby-Friendly Initiative (BFI), which promoted the uptake of the ‘Ten Steps to Successful Breastfeeding’ in hospitals across the world (WHO, 1991). This policy attempted to encourage all health professionals interacting with mothers to promote breastfeeding, and encouraged the development of appropriate training, policies and practice in hospitals, before, during and after birth. One recommendation is for skin-to-skin contact to occur between the infant and the mother soon, preferably immediately, after birth to allow the infant to make their own way to the breast and latch on naturally (Mannel et al, 2012).
Since the 1970s NHS data show slight improvements in breastfeeding (NHS, 2012). Initial breastfeeding rates, including all babies who attempted breastfeeding and those fed using expressed breast milk, were at 81% in 2010. However, this figure dropped rapidly at 6 months, when exclusive breastfeeding is still recommended, to 34%, with less than 1% of mothers exclusively breastfeeding (NHS, 2012). The highest prevalence of breastfeeding was found in women aged 30 or over, those from ethnic minorities, those who left education after 18 years of age, and those in managerial or professional careers (NHS, 2012).
Despite knowledge about the benefits of breastfeeding, rates in the UK remain low (NHS, 2012). Quantitative studies have identified certain groups that are less likely to start or maintain breastfeeding, including those with lower socioeconomic status, lower levels of education, and teenage and/or single mothers (Baker et al, 2011). Further studies have highlighted factors associated with breastfeeding cessation (Colin and Scott, 2002; Wright et al, 2006; Hauck et al, 2011; Oakley et al, 2014; Feenstra et al, 2018), such as frequent infant feeding, pain, a lack of information provision, and poor support. Less focus has been placed on the perspectives of women themselves. While qualitative literature exists, most research has either taken place outside the UK (Nelson and Sethi, 2005; Moore and Coty, 2006; Palmér et al, 2015; Feenstra et 2018), was conducted before change in UK baby-friendly practices (Huber and Sandall, 2006; Bailey, 2007; Spencer et al, 2015), or has been conducted with a specific focus, such as the use of baby cafés (Fox et al, 2015) or the experiences of specific cultures (Choudhry and Wallace, 2012). This means that it is difficult to gain an understanding of women's experiences in the UK since practice adopted a more baby-friendly approach.
Qualitative literature has highlighted the importance of breastfeeding in the maternal role (Mercer, 2004; Marshall et al, 2007) but more research is needed to understand the barriers to breastfeeding maintenance according to women themselves. In order to explore this in a UK context, this study aimed to understand the experiences that women have when breastfeeding and how this affects their ability to continue breastfeeding.
Method
Participants
Participants (n=41) were recruited through adverts on social media, specifically on breastfeeding support sites on Facebook, inviting them to take part in a survey of breastfeeding experiences.
Inclusion criteria
Participants were eligible to take part in the study if they had breastfed an infant for any period in the 5 years preceding data collection (from 2011 to 2016, when data collection took place). This time limit was applied to ensure that the experiences documented reflected recent breastfeeding practice and guidelines in the UK. The length of breastfeeding was not specified, to allow all women who had tried breastfeeding to take part (i.e. from those who had tried it just in the first few hours through to those who had fed for years).
The study received 1542 responses and interviewees were selected at random from the respondents using a random number generator from a list of participants numbered in the order in which they responded.
The study interviewed 41 women (aged 18-45 years), with data collected between May to August 2016. The breastfeeding duration ranged from less than 1 week to over 3 years, with an average of 6–12 months. In total, 16 women had chosen to cease breastfeeding at or before 6 months, and 13 women in the study were still breastfeeding at the time of interview. Of the participants, 15 had breastfed multiple infants over time, while others had only one child that they had breastfed.
Ethical approval was obtained from the University of Plymouth Faculty of Health and Human Sciences before recruitment and all ethical guidelines and data protection procedure were followed throughout the study.
Design and procedure
Semi-structured interviews, consisting of an interview schedule, were employed and lasted approximately 30 minutes. Women were asked demographic questions about themselves and their infants, as well as questions about their feeding choices (knowledge, experience and perspective on breastfeeding before giving birth, changes to perspective post-birth, emotional and physical difficulties surrounding breastfeeding, attempts to breastfeed early post-birth and subsequently); the support they received (feeling supported in their choice of feeding method, given alternatives, information and guidance on breastfeeding from health professionals, support from family); and coping (confidence, commitment and psychological resources to maintain breastfeeding). These were used as prompts to reveal how breastfeeding made the women feel and how they made sense of their experiences. These prompts also gave the interviewees a chance to attribute meaning to their experiences, giving a richer interview response.
Audio recordings were transcribed and the data analysed using inductive thematic analysis, whereby no inferences were made about the data before coding. This was done from a realist theoretical thematic approach (Braun and Clarke, 2006), involving low inference when the expressed meanings of the participants' responses were coded. This means that participants' spoken words were coded, rather than any implied meanings. This approach was to ensure that the participants' expression of their experience was directly reflected in the analysis and no assumptions were made during analysis.
Thematic analysis allows the identification and organisation of qualitative data, revealing patterns of shared meaning and experience across the data set. The analysis was done in six phases (Braun and Clarke, 2006), beginning with the authors familiarising themselves with the data. This was repeated several times until a complex understand was established. From this, potentially relevant information was identified and given an initial code. Codes that overlapped or clustered around similar features were then grouped into themes and subthemes, and thematic maps identifying how the themes interacted were produced. Themes that emerged were confirmed through a process of verification using member checking. The qualitative data were checked by the second author, who read the coded transcripts and revised themes where it was felt that they did not reflect the meaning of the original transcripts. Each coded transcript was sent to the original participant for checking (24 participants responded) and then the full analysis was also sent to all participants for checking (32 participants responded). The sample size was deemed sufficient, as data saturation, whereby no new themes or codes were identified in the last transcripts, had been reached.
Results
Four main themes were identified: attachment, provision of information and support, sociocultural pressures surrounding breastfeeding, and maternal role.
Attachment
The attachment that mothers felt towards their infant elicited negative or positive feelings depending on their breastfeeding experience. A total of 14 participants specifically discussed their positive experiences of breastfeeding and how this increased their feelings of attachment towards their infant, believing that the same bond could not be recreated in bottle-feeding.
‘People don't realise when you bottle-feed a baby, the way you hold it is totally different from breastfeeding, bottle feeding they're lying on their back, whereas breastfeeding they're kind of on their side, they're facing you more than looking up at you.’
‘I'm sure it's not just about, um, food, it's about that cuddle, that very special cuddle.’
Three of the mothers identified that when they chose to stop breastfeeding, this had a negative impact on the bond they shared with their infant.
‘She [midwife] could see how badly it was affecting me and how badly it was affecting my son, it just wasn't working.’
For those who experienced a less positive journey, breastfeeding acted as a stressor, leading to difficulties with establishing a good attachment relationship with the infant.
‘I think I lost some connection for a little while.’
Ultimately, removing breastfeeding and therefore the stressor, often allowed mothers to rekindle a positive attachment with their baby.
‘I don't really regret stopping because it was quite stressful for the both of us so and he's happier now, very happy and chubby.’
Information and support provision
This theme consisted of two main facets: information about breastfeeding provided by heath professionals, and information from lay-persons.
Overall, participants felt that they were not provided with enough information about what to expect from breastfeeding, what could go wrong and how to handle those problems.
‘I think they showed videos of babies that were newborn that were placed on their mum's chest … and they would migrate and wiggle their way to the breast and latch on perfectly … weren't reality in a way.’
‘Practise with knitted boobs and dolls and stuff …it just felt very divorced from reality, and I don't really remember much practical advice from antenatal class … they just spouted the mantra “breast is best” and didn't address any of the problems that you could come across, um, with breastfeeding.’
‘They were so pro breastfeeding as the best thing for your child. I don't know if they tried to avoid all the horror-type stories to not put women off it, but I think that probably does put women more off because as soon as … their boobs start to hurt or something they probably do give up straight away and think it's not right.’
Mothers were often given conflicting information at birth and many did not receive adequate follow-up support, outside of the normal midwife and health visitor care provided to all mothers in the UK.
‘I would know now how to go back to breastfeeding; the support was so little that I didn't know that you could sort of go back to it after.’
‘There was never any written guidance that you could do full time expressing.’
‘She [health visitor administrator] said, “I'll send you out a health visitor with an interest in feeding and she'll give you a ring”… She didn't get back to me … for 3 weeks in the end.’
Even women reporting a positive breastfeeding experience commented on the false portrayal of breastfeeding as ‘easy’, which was presented during pregnancy. The lack of preparation for the pain of breastfeeding caused by incorrect attachment was something many women experienced. Due to a lack of appropriate preparation and information, the result was physical trauma from an incorrect latch. This problem can persist if a health professional has not observed the feed, as it is difficult to know the cause of this problem when inexperienced at breastfeeding.
‘Nobody had a chance to check … they were chock-a-block. It's not a criticism on them … nobody really bothered to help me check to see if I was OK.’
‘Not taking the time to actually look and see … just presuming, asking the question, “Are you breastfeeding?”… not actually taking the time to sit down and watch you feeding.’
‘He wasn't latching on properly … after two and a half weeks I had to stop ‘cause it, it really hurt and he took a few layers of skin off.’
Participants highlighted that the information and support provided by health professionals was often contradictory and left first-time mothers confused about which advice to follow. Being provided with inconsistent care can cause a mother to lose confidence in her innate abilities to breastfeed. Additionally, 32 of the women felt that the midwives and health visitors did not have the time to dedicate to them in a relaxed manner to talk through their issues, and some felt they did not have the opportunity to ask questions about breastfeeding.
‘But you know there's no consistency in it [the breastfeeding information] … I think a lot of information scares a lot of people, especially at the beginning.’
‘The misinformation … everybody having a different opinion … not standards in evidence which really, really annoyed me.’
‘When I spoke to my GP about that she basically dismissed it completely, and said, “no, breastfed babies cannot be dairy intolerant.”’
Not all women had negative encounters with health professionals, with 13 identifying them as helpful, supportive and encouraging. An absence of this encouragement, however, often led to an increase in breastfeeding difficulties. Some midwives took a ‘hands-off’ approach to breastfeeding, letting the mother's innate abilities take over, making the establishment of breastfeeding less stressful and more successful.
‘They were good in terms of the sort of emotional support … “keep going at it, keep trying” … they were quite good, they just kept checking on me.’
‘[The midwife said] “I could sit and … help you by manhandling you and all the rest of it, but that's gonna be stressful for you and the baby, and that will be a last resort, I'd rather you went away … in a relaxing place and you will work it out.”’
‘Like a health visitor and midwife that, kind of, was a little bit more, not sympathetic towards it but a little bit more encouraging.’
It is important to note that 35 of the 41 participants highlighted that at least some health professionals involved in their care were at times unsupportive and came across as uncaring.
‘It was all done over the phone. At the end of the day I was tutted at and made to feel very small because I'd had to stop breastfeeding.’
Information was also provided by partners, family and friends, with partner support viewed as useful in encouraging breastfeeding long-term. One mother reported a less supportive approach, which led to experiences of depression in the weeks after the birth.
‘My husband is very supportive with breastfeeding.’
‘My husband was the same … he was like, “we will breastfeed, of course you will and I'll support you in any way that I can.”’
‘I was having to deal with his anxieties but at the same time put mine aside to be able to get on with normal family life … I think that is why I put more pressure on myself to have to cope with doing the right thing breastfeeding-wise and providing the best that I could.’
Help was also provided by female family members who had breastfed in the past. This practical knowledge helped some of the mothers get through difficult situations.
‘My sister was really good; I remember in the hospital she helped me put pillows under me to … to help me get comfortable.’
‘My mother-in-law prepared me … she did try to prepare me for not being able to do it because she couldn't with her two.’
‘My mum was really good ‘cause she was quite open and honest about it ‘cause she'd breastfed both me and my sister.’
Sociocultural pressures
Participants identified societal pressures that were associated with the cultural norms around breastfeeding. The views of western society and the culture in which we live have a large impact on women's attitudes to breastfeeding. In addition, feeding options are so centred on breastfeeding that education about alternatives is often left out in antenatal classes. Four mothers had strong opinions towards artificial milk, stating they judged mothers who used formula, and would not choose to use it themselves. This was echoed by one participant who had been a victim of this prejudice. One breastfeeding mother took it upon herself to educate other women about breastfeeding, and felt it was her duty to explain the benefits of breastfeeding to her pregnant friend.
‘I always look down on people who don't breastfeed straightaway if they can. It's like, “you bottle-fed from birth? Oh my God.”’
‘Formula feeding is actually not normal, it is actually substandard.’
‘I had a friend … and she was pregnant with her third child and she'd never breastfed and I kind of bullied her into it … I just kept going on about … the positive benefits of it.’
Interestingly, at the other extreme, there was also some embarrassment about the length of breastfeeding, which could be down to the sociocultural pressures of today, where it is unusual to see toddlers being breastfed.
‘I was naughty with Jordon; I breastfed Jordon until he was 26 months. He had teeth.’
Whatever the outcome of their breastfeeding experience, 11 of the women felt under pressure to breastfeed their infant. Women found that the pressure came from external sources, such as health professionals and other mothers, but also from themselves.
‘I remember going to a baby café … I remember [baby] was … hungry and I turned round to a friend [and said], “Do you think it's OK if I get the bottle out?”… I felt like they were going to launch at me.’
‘“Breast is best” and the fact that you have to ask for information on bottle-feeding, it's not just given to you as an alternative; that did make me feel quite like I'd failed.’
‘I just feel from health professional-wise that it's pushed and pushed and pushed for breastfeeding and you're not necessarily told its OK to use formula.’
‘Let people make up their own minds, I think there is an awful lot of pressure out there to do breastfeeding, um, and not make it seem that that's how it should be, you know, give them two options, explain—there's got to be fors and against for both.’
‘I was sort of telling myself it's the right, you know, it's the best thing, it's the right thing to do, I wanted it to work.’
‘It's more about our fundamental idea of what makes a good woman, what makes a good mother … I never felt any pressure to lose weight, or to look good or anything like that; what I felt pressure about was this thing of attachment parenting and breastfeeding.’
‘Because I hadn't managed to give birth, I was absolutely adamant that I would feed him.’
‘I'm not anti-people feeding their babies formula, of course, but for me it's not the right, it wasn't what I wanted to do.’
One mother felt that breastfeeding would eventually ‘die out’ because so many women were not able to establish a good routine with their infant, meaning they will have little knowledge to pass on.
‘I just look at society today and I think eventually, breastfeeding's really gonna take a hammering … it will die down … it's possible it could die out.’
Maternal role
The final theme highlighted the part that breastfeeding played in the maternal role, with 10 mothers inferring that to breastfeed was to be a good mother. This was internalised by four participants.
‘I would've felt like I'd failed if I hadn't been able to breastfeed.’
‘Just feeling that this is my core job is to feed this child in this way.’
For mothers who could not, or struggled to, breastfeed, this could cause emotional problems if they had anticipated being able to breastfeed. Many felt they were not living up to the standard expected of them.
‘I felt I'd let her down, yeah, I did feel that I'd sort of, not been able to give her what I should've been able to give her.’
‘I was more devastated than she was, um, yeah I was completely bereft, um, when I had to stop and it's still kind of a bit upsetting.’
‘I couldn't give birth properly and then I couldn't feed him properly as such.’
‘I didn't feel like I was doing everything that I could to give my kids the best start in life.’
‘I felt it was all tied up in my worth as a mother … this is about whether or not you're a good mum.’
This was particularly profound for women who did not have immediate skin-to-skin contact with their infant, often due to a complicated birth.
‘They took her away as soon as she was born and then I didn't see her for about 6 hours and that was pretty disastrous for me, um, because as soon as she went out of the room, she didn't exist.’
‘By the time I had seen her, she'd already had several syringes of formula … No one approached me and said, “Do you want to try and express?’; I was just left 9 hours.’
Finally, it was felt that society expected mothers to behave a certain way and to define themselves as mothers rather than as individuals in their own right.
‘I should want to be with my daughter all the time and I should happily give up my everything, um, in order to, to fulfil this little creature's needs.’
Discussion
This study identified four themes associated with breastfeeding: attachment, provision of information and support, sociocultural pressures and the maternal role. The attachment between a mother and her infant begins in pregnancy and birth (Hammonds, 2012). Studies have identified that breastfeeding mothers show more sensitivity to their infants' needs, which could explain why breastfeeding mothers in this study felt a more positive attachment towards their infants (Britton and Britton, 2006).
The maternal role attainment theory stipulates that early skin-to-skin contact, early breastfeeding and minimal separation between mother and infant while in hospital needs to be promoted to help mothers settle into their role (Husmillo, 2013). The theory suggests that mothers go through a period immediately after birth where they follow advice from experts and copy their behaviour to learn how to meet their infant's needs (Mercer, 2004). Most women settle into their role as a mother at around 4 months postpartum when the baby has become part of family life and the mother is confident in her care abilities. It is at this point when the mother reports the greatest feelings of attachment to the infant (Mercer, 2004; Husmillo, 2013). This theory was supported by this study, although mothers indicated that they needed further support and information beyond 4 months postpartum. The recurring theme throughout the interviews was that the information provided by health professionals was inadequate, suggesting that the support up to 4 months postpartum was not always sufficient to settle into their maternal role.
National Institute of Health and Care Excellence (NICE) guidelines state that health professionals should have suitable time to spend with new mothers and their infants to establish and maintain a successful breastfeeding relationship. There should also be good communication between health professionals and mothers to establish a good breastfeeding technique (NICE, 2015), but this research suggests that this was not always the case. Health professionals need to provide practical support by helping mothers to recognise the signs of hunger in infants, cluster feeding behaviours, sleep/wake patterns, and nappy contents, which strengthens trust that breastfeeding can meet the infant's needs (Fraser and Cullen, 2003). Additionally, health professionals need to spend more time observing feeding techniques. Physical support could help overcome problems and reduce the number of women who do not continue with breastfeeding (Fraser and Cullen, 2003).
While the ‘breast is best’ campaign promotes the importance of breastfeeding, this study suggests that some women feel under pressure from health professionals to breastfeed. If women felt under less pressure, they may feel more relaxed, making the hormonal process of breastfeeding easier (Blyth et al, 2002). Health professionals should also be prepared to suggest formula feeding in cases where a mother cannot breastfeed, as it is imperative that women receive the knowledge and support they require to use other approaches.
Research has examined voucher schemes for mothers who are exclusively breastfeeding, in an attempt to overcome negative attitudes. The study was piloted in one deprived area where less than 20% mothers were breastfeeding by the time their infant was aged 6–8 weeks old (Hives-Wood, 2013). This study suggests that a more beneficial approach might be to invest in greater health information and support for first-time mothers.
Having a supportive partner is also associated with increased breastfeeding duration (Rempel and Rempel, 2011; Maycock et al, 2013); however, this support alone is not enough to maintain a successful breastfeeding routine (Rempel and Rempel, 2011). Alongside the pressures of a new role, looking after a newborn infant, and trying to maintain a breastfeeding relationship, women can be left feeling overwhelmed. Mental health can affect breastfeeding, and those with depression and anxiety disorders can cease breastfeeding sooner than recommended, with a negative impact on mother and infant (Mannel et al, 2013). Fathers need to be encouraged to provide support where needed.
The need to breastfeed is associated with the cultural view that breastfeeding is the best option for infants' health and the perceived social norms of how to feed an infant (Guttman and Zimmerman, 2000). The pressure on women to breastfeed is immense, and women incorporate the need to breastfeed into their identity as a mother (Marshall et al, 2007). This can affect a mother's mental wellbeing as she may begin to question her role if she struggles to breastfeed. Interviews conducted with women having difficulties with breastfeeding have shown that they felt as though they had lost control and were failing as mothers (Shakespeare et al, 2004). This was supported by these findings. Societal pressures are more difficult to overcome, but ensuring that women are praised for the effort they put into breastfeeding, regardless of duration, will help to promote breastfeeding.
Strengths and limitations of the study
The study allowed participants to openly discuss issues of breastfeeding, both positive and negative. The study used a qualitative approach to understand the experiences of women who have breastfed. The limitation of this approach is that the data cannot necessarily be extrapolated to a wider population of women; however, the number of women recruited to this study and the representation across the UK suggests that this study may reflect breastfeeding experiences more widely.
Conclusions
This study aimed to analyse the conditions that might influence women's choice to breastfeed and highlighted the roles that attachment, maternal role, sociocultural pressure and provision of information and support may play in influencing whether or not women choose to breastfeed. This study has shown that a lack of practical appropriate support may be a key reason for early cessation. This could be addressed by increasing access to health professionals, particularly midwives, initially after discharge to ensure difficulties are detected and addressed. The study also suggested that, for some mothers, ceasing breastfeeding is often not a choice, but is necessitated by the circumstances that women face postpartum and exacerbated by a lack of information. It was found that those who were able to continue breastfeeding often did so due to internal pressures to continue, and to live up to their own ideals of being a good mother.