Background
The importance of breastfeeding on the health of both children and mothers is significant [
1]. Breastfeeding rates (especially for 'exclusive breastfeeding') have not, however, reached their targets in several countries for example in the United Kingdom and the United States [
2,
3]. Thus, nursing studies have focused on the factors and interventions that affect the choice of feeding method, initiation of breastfeeding and duration [
4‐
9]. One of the factors known to play a role is attitude towards infant feeding.
Mothers' breastfeeding attitudes are known to influence infant feeding choice [
7,
10]. According to parents, breastfeeding is recognised as being better for the newborn and a natural and cheap way to feed the infant [
11,
12]. Negative images or experiences about breastfeeding, including regarding breastfeeding as embarrassing, uncomfortable or painful [
12‐
14], have been indicated as reasons for preferring bottle-feeding. Researchers have described the breastfeeding attitudes of health professionals [
15‐
17], parents [
18,
19], students [
20,
21] and the general public [
22]. Attitude is defined as a bipolar concept that has a cognitive, affective and behavioural component and is a response to a stimulus [
23].
In this study, breastfeeding attitudes reflect people's views on infant feeding. Attitudes can appear stable, but can change. For example, a Swedish study indicated that the breastfeeding attitudes of health professionals could be shifted to show a more positive trend through educational intervention [
17].
Previous studies have mostly focused on mothers' attitudes in the prenatal [
12,
24] or postpartum periods [
14], but little information exists on both parents' prenatal breastfeeding attitudes [
11]. However, since health professionals normally encounter pregnant parents, breastfeeding attitudes could be improved. A study in Taiwan indicated that breastfeeding attitude scores were higher after prenatal breastfeeding education intervention [
25]. Furthermore, British studies have found that positive prenatal attitudes in mothers are linked to the intention and initiation of breastfeeding [
24] and that attitude scores correlated with their spouses' scores [
26]. Negative attitudes in fathers reduced breastfeeding initiation, according to a German study [
27]. In addition, positive prenatal breastfeeding attitudes were linked to continued breastfeeding at least four weeks postpartum among teenage Canadian mothers [
28]. An association between breastfeeding attitudes and duration was also found in an Australian study [
29].
Studies conducted in the British Isles have indicated that the parents of breastfed infants have more positive attitudes towards breastfeeding than the parents of formula-fed infants [
11]. Furthermore, breastfeeding mothers seem to be more supportive of breastfeeding than their spouses [
30], but American studies have found that the breastfeeding attitudes of fathers can be more positive than the mothers predict [
19,
31]. The father's attitude is important because his role as a breastfeeding supporter is critical for the mother [
32]. Intervention studies conducted in Italy and Brazil have indicated that the inclusion of fathers in breastfeeding promotion programmes has effects on the duration of exclusive breastfeeding and enhances maternal support [
33,
34]. Studying both parents' breastfeeding attitudes would, therefore, seem to be useful.
Studies on breastfeeding attitudes have been conducted in various cultures, but few studies [
17,
35] hail from Scandinavia. Breastfeeding initiation rates in Scandinavia are high [
36]; for example, in Finland 99% of mothers initiate breastfeeding. Seventy-seven per cent of newborns, however, receive donor milk or artificial milk during their hospital stay [
37]. Breastfeeding rates decrease rapidly following discharge and only 60% of one-month-old infants are exclusively breastfed [
38], which in Finland means that the child receives only breast milk, vitamin D and possibly small amounts of water. At six months of age 60% of infants receive breast milk, but only 1% are exclusively breastfed [
38], even though both the World Health Organization [
39] and the Social and Health Ministry of Finland [
40] recommend exclusive breastfeeding at this age. Consequently, information about parents' breastfeeding attitudes is necessary so that interventions to promote breastfeeding can be planned.
Breastfeeding attitudes are measured using different scales, mainly using paper forms. Breastfeeding in a public place or in front of others is a commonly tested issue [
10,
18,
30,
41]. One of the most frequently used instruments in attitude studies is the Iowa Infant Feeding Attitude Scale, which consists of items on the health and practical benefits as well as the financial benefits of breastfeeding [
11,
21,
42‐
44]. However, the health benefits of breastfeeding derived from the attitude scale can overlap if breastfeeding knowledge and attitudes are measured simultaneously and with different scales. In addition, the father's role in breastfeeding has seldom been included in the attitude questions even though fathers are now actively involved in childcare [
45]. Interviews [
18], questionnaires using the Likert scale [
26,
30] and scenarios [
30,
41] have been used in studies on breastfeeding attitudes. The electronic data collection method, however, is rarely used to ascertain breastfeeding attitudes [
46], even though young people are familiar with the Internet [
47]. In addition, the relationship between breastfeeding attitudes and the intention [
20,
21] or initiation [
14] of breastfeeding is commonly measured but differences in demographic characteristics have been less of a focus in breastfeeding attitude research [
24]. Therefore, the aim of this study was to describe parents' prenatal breastfeeding attitudes using a web-based survey. The specific research questions were:
1.
What kinds of attitudes do pregnant families have towards breastfeeding?; and
2.
How do attitudes differ in relation to demographic characteristics?
Discussion
The main finding was that parents regard breastfeeding positively but found it important that fathers can also participate in the infant feeding. In this sense, equality in feeding was a new aspect in breastfeeding attitude studies. It was evident that fathers wanted to be involved in choosing the feeding method and found it important to play an active role in feeding. The respondents who were expecting their first child regarded a joint parental decision about the newborn's feeding method as especially significant. Both parents valued breastfeeding and nearly all mothers intended to breastfeed. Previous studies have also indicated that mothers [
24,
26] who intend to breastfeed have partners [
18] with positive attitudes towards breastfeeding.
There is scarce information about public breastfeeding in the Finnish culture. The majority of respondents regarded breastfeeding at home or in a public place as appropriate, but 33% did not regard the public breastfeeding of a one-year old child at a hamburger restaurant as acceptable. Studies conducted in other cultures have indicated that breastfeeding in front of others might be seen as embarrassing [
57,
58]. In the USA, public breastfeeding is protected by law e.g. in Arkansas [
59]. Studies on African and Indian cultures have indicated that non-breastfeeding might be seen as evidence that the mother has been unfaithful or that she is HIV-positive [
60,
61]. Overall, public breastfeeding seems to be a culture-related issue.
Attitudes differed when parity was considered. The parents expecting their first child were more worried about the effect of breastfeeding on the father's relationship with the baby and his feeling of being an outsider than those who had at least one child. A Swedish qualitative study indicated that some first-time fathers experienced negative feelings when the mother was breastfeeding [
45]. It is possible that the trend for equal parenthood means that breastfeeding is seen as a problematic issue. However, we noted that the parents who had at least one child did not think breastfeeding was as complicated as the parents who were expecting their first child did. This could imply that previous breastfeeding experience had been positive or that the respondents relied on their ability to resolve possible problems, whereas the parents who were expecting their first child had no prior experience on which to base their opinion.
Breastfeeding attitudes differed when education was considered. Sittlington and colleagues found the same result [
24]. In the current study, respondents with a moderate level of education had more negative views on breastfeeding than those with a high level of education. No significant differences were found, however, when low levels of education were examined. This might be explained by the fact that some of those with the lowest level of education were students, e.g. at university, and they had not completed their education at the time of response.
According to this study, respondents over 27 years old regarded breastfeeding as less troublesome than those who were younger. Nonetheless, there were more parents who were expecting their first child in the youngest age group than in the other groups (p < .001) and they had no experience of breastfeeding. Therefore, some of them might have seen breastfeeding as a complicated method of feeding, although the reasons for this are unclear.
In addition, respondents with high levels of breastfeeding knowledge considered breastfeeding as less difficult and less exhausting than those with moderate or low levels of knowledge. This suggests that those who knew a lot about breastfeeding also had a very positive view of it.
The reliability of the BKAC scale is considered fairly good for the first measure because the Cronbach's alpha coefficients of the attitude dimension varied between 0.602 and 0.858 for each factor. The elimination of the item about the feeding of the newborn by both parents would have increased the Cronbach's alpha coefficient, but the item was regarded as relevant on the basis of experts' evaluations. Nevertheless, a Cronbach's alpha coefficient of over 0.6 has been described as acceptable [
62]. The Cronbach's alpha coefficient was 0.84 in the knowledge dimension and 0.932 in the confidence dimension. The validity of the BKAC scale was measured using the CVI. Evaluations by all five breastfeeding experts rated 18 of the 21 attitude items as highly or quite relevant and thereby the scale-level content validity index, universal agreement calculation method was 0.857. The scale-level content validity index, averaging calculation method and item-level content validity index of the attitude items was 0.96, indicating the high validity of the dimension [
63].
Nonetheless, this study has some limitations. First, the low response rate limits the generalisation of the results. Those who had poor computer skills or who were not interested in the research issue might have bypassed the study. Therefore, the results might indicate a misleadingly positive view about breastfeeding, although the high breastfeeding initiation rates in Finland would indicate that most mothers do regard breastfeeding as important. Furthermore, the small proportion of fathers needs to be taken into consideration. In this study, there were both fathers and mothers who regarded breastfeeding as not important and their responses seemed to be real; this implies that the respondents did not wilfully offer socially desirable answers. The response rate (21%) in this study was similar, however, to that of the web-based survey performed by Lucero and colleagues, in which 16.6% of paediatricians answered a questionnaire concerning attitudes, knowledge and clinical practices regarding breastfeeding and smoking [
46].
A second limitation is that the families were informed only once about the study, so it is possible that some could have forgotten about it. The public health nurses said that some of the mothers placed the covering letter inside their maternity card and found it there the next time they visited the MHCC. In such cases, the public health nurses reminded the mothers and fathers to participate in the study if there was still time to respond. The participants were anonymous so the researchers had no opportunity to remind them. The chance to participate anonymously in the study might have increased interest in it, however.
The results of this study could be used in the development of breastfeeding counselling. The fathers' active attitudes towards and the image of breastfeeding of first-time parents need to be taken into account in clinical nursing. More studies are now required to examine equality in feeding. Follow-up studies are also needed to discover whether breastfeeding attitudes change between the prenatal and postnatal periods.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SL participated in the design of the study, data collection, performed the statistical analysis and drafted the manuscript. AE contributed to the analysis and critically revised the manuscript. TP and A-MP participated in the design of the study, supervised the study and critically revised the manuscript. All authors have given their approval for the manuscript to be submitted in its present form.