Normalising breastfeeding within a formula feeding culture: An Irish qualitative study

doi:10.1016/j.wombi.2016.10.002

Women and Birth

Volume 30, Issue 2, April 2017, Pages e103-e110

https://doi.org/10.1016/j.wombi.2016.10.002 Get rights and content

Abstract

Background

Breastfeeding rates in Ireland are among the lowest in Europe. Breastfeeding groups can provide support, information, and friendship for women. However, there is little research exploring community breastfeeding groups led by Public Health Nurses providing universal maternal and child care to all postnatal mothers in the community in Ireland.

Aim

The aim of this study was to explore breastfeeding women’s experiences of a Public Health Nurse led support group.

Methods

A qualitative descriptive design to explore women’s experiences of a community breastfeeding support group was conducted. Data were collected using one to one interviews with breastfeeding women (n = 7) in a primary healthcare setting. Transcripts were analysed using Burnard’s thematic content analysis.

Results

The overall theme identified was ‘normalising breastfeeding’ which emerged from the subthemes ‘socialising and sharing’, ‘information and support seeking’, ‘building confidence’, ‘overcoming embarrassment’, ‘negative perceptions of others’, and ‘promoting breastfeeding to others’.

Discussion

Women who attended the PHN led breastfeeding support group found it to be a cocoon of ‘normality’, whereas breastfeeding was considered almost something to be ashamed of in other circumstances. Many women attributed their success with breastfeeding to the support group.

Conclusion

Facilitating a sense of normalcy for breastfeeding women at individual, community and societal levels was essential in promoting breastfeeding. The community support group was influential in normalising breastfeeding for a sample of women, by minimising the potential for embarrassment, promoting social interaction and sharing, building confidence and knowledge. This buffered the effects of negative attitudes of others and personal feelings of shame.

Introduction

Breastfeeding is widely considered to be the best option for both baby and mother, promoting health and preventing disease. Increasing evidence demonstrates the health benefits for infants including enhanced immunity¹ higher intelligence scores² and reduced risk of certain health problems, including childhood obesity.3, 4, 5 This is of particular importance as the World Health Organisation (WHO) states that Ireland is on course to become the most obese country in Europe by 2030.⁶ Therefore, policies have been developed recommending that babies be breastfed exclusively up to 6 months of age, with continued breastfeeding up to 2 years of age. Additionally, the Ten Steps to Successful Breastfeeding Initiative advocates for the development of support groups in the community.⁷ Yet despite national and international breastfeeding policies, breastfeeding initiation rates in Ireland are the lowest in Europe⁸ and among the lowest in the world, at 55.7% in 2010.⁹ These figures stand in stark contrast to breastfeeding initiation rates of 81% in the UK and 90% in Scandinavian countries.⁸

The low breastfeeding rates are also of concern as Ireland has the second highest fertility rates in Europe.¹⁰ Furthermore, Irish breastfeeding continuation rates are low. A study of Irish women demonstrates that 40% had ceased breastfeeding by 4 weeks and only one was still exclusively breastfeeding at 6 months.¹¹ Notably, Irish breastfeeding rates increased by 7% from the year 2005 to 2010.⁹ However this increase may be due to the changing characteristics of women in Ireland, such as the greater number of Eastern European mothers for whom breastfeeding is the cultural norm.¹²

Decisions on infant feeding methods are complex and influenced by socio-demographics, psychosocial, health and cultural factors.¹³ In Ireland socio-demographic factors associated with breastfeeding include third level education,11, 14 previous breastfeeding experience, 2 or more postnatal Public Health Nurse (PHN) visits, and having a positive attitude towards breastfeeding.¹⁴ In contrast, factors associated with low initiation and continuation rates include: lower socio-economic backgrounds, tiredness, frequent feeding, perceived inadequate milk supply, poor support from partners and family, embarrassment, poor cultural acceptance of breastfeeding and pressure to give formula.¹¹ Correspondingly, women who attend breastfeeding groups are generally older and higher income earners.¹⁵ Pressure to formula feed is particularly concerning as the financial investment for formula promotion is up to 100 times greater than that spent on breastfeeding promotion in Ireland.¹⁶

Breastfeeding supports valued by women in Ireland include one to one support, chat rooms and blogs, drop-in baby clinics and PHN breastfeeding support groups.¹⁷ However, it has been established that initiatives must be directed at the antenatal period, as 50% of women decide whether to breastfeed before pregnancy/birth¹⁷ and women with ante-natal intention continue to breastfeed for longer.¹³ Furthermore these initiatives should be inclusive of partners and relatives, and should be directed at the entire population to promote more positive perceptions of breastfeeding on a societal level.¹³

Most breastfeeding support is required in the first few weeks from community midwives or Public Health Nurses (PHN), as breastfeeding is a learned skill. Additionally, this is the time when most women cease breastfeeding.11, 13 These professionals have a particularly important role as earlier hospital discharges increase breastfeeding support needs in the community.¹⁸ In Ireland, the PHN is the health professional that provides breastfeeding support to women and their babies in the home with a first visit ideally within 48 h of hospital discharge. The PHN formulates an individualised plan of care in partnership with the woman¹⁷ and links women with professional and voluntary breastfeeding support services in the community.¹⁹

All PHNs require accredited breastfeeding education in order to effectively promote breastfeeding.¹⁹ The 20 h breastfeeding UNICEF/WHO course meets the necessary criteria and should assist in addressing conflicting advice. This is of great importance as breastfeeding support from well trained professionals, has been shown to increase breastfeeding continuation rates and maternal satisfaction with breastfeeding.¹⁸

The WHO has advocated for the development of breastfeeding support groups in the community to support breastfeeding women⁷ and it is the role of the PHN to develop and facilitate such groups.²⁰ Yet PHNs rarely evaluate breastfeeding support groups¹⁷ and research into professional and lay breastfeeding support groups is limited.¹⁵ Nevertheless a study on drop-in clinic attendees demonstrated positive breastfeeding outcomes as women (n = 80) described how the group supported them to continue breastfeeding.²¹

Peer support has demonstrated positive breastfeeding outcomes18, 22 although not always consistently.²³ However an element of peer support delivered pre and postnatally may add to the success of a programme.¹⁸ Therefore, it can be a useful component of, or adjunct to other initiatives. Evaluation of peer-led groups in socially deprived areas found positive breastfeeding outcomes, with their success attributed to their focus on local cultural norms.²⁴

Scottish research findings indicated that women preferred breastfeeding support groups over one-to-one support due to the interactional, verbal, visual, and emotional benefits of a group atmosphere.²⁵ Therefore professional-led support groups appear effective in supporting breastfeeding women and work best when peer and professional support are combined, as demonstrated in a systematic review of 36 papers.¹⁸ The evidence suggests that culturally sensitive breastfeeding support groups with peer support are most successful, particularly with women from lower socio-economic groups.18, 24

A cluster randomised control trial in the UK¹⁵ which aimed to evaluate nurse led breastfeeding support groups in deprived areas, increased the number of local breastfeeding support groups from 10 to 27 groups (n = 1310 mothers). However, results demonstrated no significant differences in breastfeeding outcomes.¹⁵ A follow up study revealed that professional communication problems and poor organisational support hindered the success of this initiative and thus concluded that breastfeeding support groups require positive organisational support to be effective.²⁶ Lack of organisational support for breastfeeding in the community is a recurring theme, particularly in the Irish setting and should be addressed with increased resources and policy.14, 17, 19, 26

In Ireland, over half of PHNs facilitate breastfeeding support groups in their areas, but less than 50% of mothers indicated that they attended such groups.¹⁷ Whilst 37% of those attending reported being ‘very satisfied’, 22.5% were ‘not at all satisfied’.¹⁴ Despite these varying results, findings indicated that women who attended breastfeeding support groups breastfed for as long as they had planned.¹⁴ No data were provided in these Irish papers on the women’s experiences and perceptions of attending a PHN-led breastfeeding support group. Therefore the aim of this study is to explore women’s experiences of attending a PHN–led breastfeeding support group in a formula feeding culture.

Section snippets

Design and rationale for design

A qualitative descriptive design was the method of choice as straight description of the women’s experiences was desired. By using this design the focus is on descriptive validity, which is a comprehensive account of phenomena that both the researchers and participants would agree is accurate.²⁷

Ethics

Prior to data collection, ethical approval was sought and granted by the local Clinical Research Ethics Committee REF: ECM4 (n) 12/03/13.

Recruitment of participants

A purposeful sample of participants were recruited following

Demographic findings

In terms of the characteristics of the sample, women were aged 25–35 years, married and had a third level education, which is typical of breastfeeding mothers generally. Five women had a vaginal delivery and the remaining two had caesarean sections, one elective and one emergency. Six women were primiparous. For the remaining woman, this was her third child and she had previously breastfed (b/f) her children. Infants varied in age from 3 ½ months to 14 months at the time of interview and most (n

Discussion

Most women were primiparous, married and had a vaginal delivery. This sample of breastfeeding women are typical of the profile of breastfeeding mothers but not representative of the general population of mothers in Ireland.11, 13, 14, 17 ‘Normalising breastfeeding’ was of vital importance to the women involved. This emerged from the subthemes: socialisation and sharing; information and support seeking; building confidence; overcoming embarrassment; negative attitudes of others; and promoting

Conclusion

‘Normalising breastfeeding’ was the central theme emerging from this study, as women experienced negative attitudes from others and reported embarrassment and shame in relation to breastfeeding, particularly in public. The PHN led breastfeeding support group supported women to breastfeed and promoted a sense of normality through socialisation, sharing, confidence building and provision of information.

Implications/recommendations for practice, policy, education and research

This study supports recommendations for community based breastfeeding support groups, particularly group approaches with professional support. The social atmosphere was an important contributor to the positive perceptions of the group; its success in helping women to maintain and normalise their breastfeeding experience and building confidence. Creating this nurturing space is an important consideration for facilitators of such groups but perhaps needs to be further extended to integrate the

Ethics approval and consent to participate

Ethical approval was granted by the local Clinical Research Ethics Committee REF: ECM4 (n) 12/03/13. Informed consent was obtained from all participants.

Availability of data and materials

A graph showing the development of categories, subthemes and themes is available as Appendix 1.

Competing interests

None.

Funding

None.

Acknowledgments

The authors wish to thank the women who gave their time to participate in the study. No competing disclosures.

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To meet study aims, a homogenous sample of studies from developed countries was systematically selected for inclusion so that clear, context-specific definitions of guilt and shame could be generated. Given cultural variation in breastfeeding practices and maternal wellbeing between developed (Leahy-Warren et al., 2017) and developing (Wanjohi et al., 2017) countries, generated definitions may serve as a key comparator in the event that future research seeks to compare cross-cultural differences in guilt and shame experiences within an infant feeding context. Constructed definitions provide an in-depth analysis of the key characteristics which distinguish infant feeding-specific guilt and shame.
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Much evidence around public breastfeeding does not reflect experiences of the key stakeholder, the breastfeeding woman, and focuses upon the audience. Selective evidence has explored breastfeeding experiences revealing challenges with public breastfeeding as a serendipitous finding. Although women's experiences have been explored in specific contexts, insight into commonalities reflective of an international perspective is unknown.
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An integrative review allows inclusion of findings beyond empirical evidence. Whittemore and Knafl's approach was used to capture and analyse evidence from varied sources to provide understanding of a phenomenon from diverse methodologies. PubMed, Medline, Ovid emBase, Scopus, Science Direct, the Cumulative Index of Nursing and Allied Health Literature and PsychINFO were searched. Inclusion criteria included publications in English after 2005 offering descriptions of women's experiences. Data evaluation included assessment of literature quality. A constant comparison approach involved comparing, analysing and drawing similar concepts into themes.
Integration of women's experience with public breastfeeding from 27 publications covering 12 countries revealed two key themes, what women shared as ‘enhancing’ and ‘challenging’. Challenges included four subthemes: ‘drawing attention’, ‘sexualisation of breasts’, ‘awareness of others’ discomfort’, and ‘efforts not to be seen’. Enhancing incorporated subthemes: ‘supportive audience’ and ‘confidence’.
Challenges confirm an international commonality that women encounter during public breastfeeding suggesting a multilayered approach addressing community and societal behaviours is required. Insight to enhance public breastfeeding experiences offers direction to improve support.

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Original Research - QualitativeNormalising breastfeeding within a formula feeding culture: An Irish qualitative study

Abstract

Background

Aim

Methods

Results

Discussion

Conclusion

Introduction

Section snippets

Design and rationale for design

Ethics

Recruitment of participants

Demographic findings

Discussion

Conclusion

Implications/recommendations for practice, policy, education and research

Ethics approval and consent to participate

Availability of data and materials

Competing interests

Funding

Acknowledgments

Curr Paediatr

Soc Sci Med

Soc Sci Med

Midwifery

Soc Sci Med

Nurse Educ Today

Midwifery

Midwifery

Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analysis

Proportion of overweight and obese males and female to increase in most European countries by 2030, say latest projections by WHO

Global strategy on infant and young child feeding

The optimal duration of exclusive breastfeeding. The 54th world health assembly

National perinatal statistics report 2013

Perinatal statistics report 2011

World fertility patterns 2013

The prevalence and determinants of breastfeeding initiation and duration in a sample of women in Ireland

Public Health Nutr

Explaining differences in breastfeeding rates in Ireland: evidence from the national perinatal reporting system 2004–2010

The national infant feeding survey 2008

Original Research - Qualitative
Normalising breastfeeding within a formula feeding culture: An Irish qualitative study