Background
Domain | Examples | |
---|---|---|
Capability | Physical | Skills, strength, stamina |
Psychological | Knowledge, confidence, memory | |
Opportunity | Social | Social norms, interpersonal influences |
Environmental | Resources, physical environment | |
Motivation | Automatic | Impulses, desires, addiction |
Reflective | Beliefs, intentions |
Methods
Study design and sample
Researchers and positionality
Ethics, consent, permissions and permission to publish
Data production
Participant | Phase 1 | Phase 2 | Total word count | ||||
---|---|---|---|---|---|---|---|
1st Pre-Interview Timeline Task | Phase 1 Word count | 2nd Pre-Interview Thought Bubbles Task | 2nd Pre-Interview Collage Task | 3rd Pre-interview Sandboxing task | Phase 2 Word count | ||
Anna |
✓
| 21,462 |
✓
|
✓
|
✓
| 15,294 | 36,756 |
Becky |
✓
| 2836* |
✓
| x |
✓
| 12,584 | 15,420 |
Cat |
✓
| 8043 | x | x |
✓
| 12,292 | 20,335 |
Donna |
✓
| 17,036 |
✓
|
✓
|
✓
| 17,792 | 34,828 |
Ellie |
✓
| 6680 | n/a | n/a | n/a | n/a | 6680 |
Fiona |
✓
| 4787 | x |
✓
|
✓
| 7824 | 12,611 |
Gaby |
✓
| 9714 | x |
✓
|
✓
| 11,494 | 21,208 |
Hayley |
✓
| 9116 |
✓
| x |
✓
| 12,253 | 21,369 |
Imogen | x | 6532 |
✓
| x |
✓
| 10,237 | 16,769 |
Jess | x | 9339 |
✓
| x |
✓
| 11,130 | 20,469 |
Total | 8 | 95,545 | 6 | 4 | 9 | 110,900 | 206,445 |
Data analysis
Results
Demographics and self-reported health behaviours
Pseudonym | Highest qualification | Parity (maternal age at birth (years)) | Gestation (weeks) at recruitment | Smoking/e-cigarette use/smokefree environment during pregnancy | Alcohol use during pregnancy | Infant feeding experiences and intentions |
---|---|---|---|---|---|---|
Anna | NVQ 2 | 2 (23, 26) | 8 | Smoked on previous pregnancy, non-smoker during current pregnancy | Moderate* drinking during current pregnancy - “The odd one” | Attempted on first child, but moved to formula within first few days |
Plans to formula feed current baby | ||||||
Becky | NVQ 2 | 1 (22) | 18 | Prior to previous pregnancy was smoking 15–20/day. Changed to e-cigarette and has remained an e-cigarette user throughout current pregnancy | Almost abstinent during current pregnancy - Not generally, but would have a small amount on special occasion (eg: her birthday). | Combination fed first child |
Plans to attempt to breastfeed | ||||||
Drank moderately during previous pregnancies | ||||||
Cat | NVQ 1 | 1 (23) | 10 | Smoker during current pregnancy – 1-2 per day | Moderate alcohol consumption during current pregnancy - One or two drinks | Did not attempt to breastfeed first child |
Conflicted about whether to try to initiate breastfeeding. | ||||||
Donna | Degree | 2 (28, 30) | 20 | Non-smoker; partner is a non-smoker; avoids smokey environments | Abstinent during current pregnancy; generally drinks a small amount | Attempted on first child, but moved to formula ‘quite quick’. Breastfed second child for 11 months. |
Plans to breastfeed current baby | ||||||
Ellie | NVQ 2 | 1 (25) | 10 | Not discussed but home was not smokefree | Not discussed | Not fully discussed, but plans to buy a steriliser |
Fiona | None | 2 (17, 27) | 9 | Not discussed | Abstinent | Unclear how fed previous baby, but used a steriliser and bottle. |
Plans to formula feed current baby. | ||||||
Gaby | GCSEs | 3 (22, 24, 27) | 6 | Non-smoker | Abstinent – always abstinent | Tried to breastfeed three previous children (two quickly transitioned to formula; one breastfed for a month before transition to formula). |
Plans to formula feed current baby, but did state would try to initiate breastfeeding. | ||||||
Hayley | A Levels | 1 (29) | 29 | Non-smoker during current pregnancy – used to smoke | Abstinent during current pregnancy | Breastfed first baby for three months with one bottle of formula per day. |
Hopes to breastfeed current baby for at least two weeks. | ||||||
Almost abstinent during previous pregnancy would have a small amount on special occasion (eg: her birthday). | ||||||
Imogen | NVQ 2 | 1 (24) | 8 | non-smoker during current pregnancy | Abstinent during current pregnancy; Rarely drinks anyway | Not discussed, but had a traumatic birth and postnatal depression |
Jess | GCSEs | 0 | 11 | Smoker – unsuccessful quit attempt in current pregnancy; trying to cut down | Abstinent during current pregnancy | Will attempt to initiate breastfeeding; plans to combination feed |
“I have never liked, I don’t, obviously, disagree with it, I agree with it but I, it’s never, I’ve never, I couldn’t do it, it’s something that I don’t agree with myself doing it, I just can’t get the hang of it.” (Cat)
Barriers and facilitators to following public health guidance during pregnancy
Drivers of behaviour: barriers (−) and facilitators (+) | COM-B domain |
---|---|
Remaining smokefree during pregnancy | |
Knowledge of potential harm (+), including from health professionals (+/−); high (+) or low (−) Carbon Monoxide test readings; belief that harm from smoking is real (+) or exaggerated (−) | Capability – psychological |
Opportunity - social | |
Motivation - reflective | |
Pregnancy related nausea (+) | Capability - physical |
Stress (−) | Capability - psychological |
Stigma related to smoking during pregnancy and pressure to stop smoking leads to hidden smoking in the home and car (−); smoking in pregnancy normalised (−); strong family views that smoking is bad (+) | Opportunity – social |
Opportunity – environmental | |
Motivation - reflective | |
Nicotine addiction (−); cravings to smoke (−); feeling that e-cigarettes were unable to deliver sufficient nicotine to reduce cravings (−); life long non-smoker (+); association between drinking alcohol and smoking leads to reduced cravings when not drinking alcohol (+) | Motivation- automatic |
Remaining abstinent from alcohol during pregnancy | |
Knowledge of guidelines (+/−) including from health professionals (+/−); belief that any alcohol is dangerous (+) or only heavy alcohol use is dangerous (−); belief that alcohol is dangerous reduces appeal (−) | Capability – psychological |
Opportunity - social | |
Motivation - reflective | |
Pregnancy related nausea and tiredness reduce appeal (+); age and caring responsibilities for children make ‘hangovers’ unappealing (+) | Capability – physical |
Opportunity - social | |
Motivation - reflective | |
Alcohol consumption in public is highly stigmatised (+/−); partners and family members encourage alcohol consumption in the home (−); | Opportunity - social |
Opportunity – environmental | |
Socialising largely takes place in premises serving alcohol and few non-alcoholic options (−); feelings of isolation from social group when not drinking alcohol (−) | Opportunity - social |
Opportunity – environmental | |
Willpower sufficient to resist alcohol (+); alcohol associated with relaxation and pleasure, leading to strong desire to drink alcohol (−) | Motivation- automatic |
Opportunity - social | |
Breastfeed exclusively for six months | |
Knowledge of guidelines (+/−) including from health professionals (+/−); belief that breastmilk is superior to formula (+/−); belief that exclusive breastfeeding is important (+/−); belief that breastfeeding beyond the early days and weeks is important (+/−) | Capability – psychological |
Opportunity - social | |
Motivation - reflective | |
Breastfeeding (+) or formula feeding (−) positioned as the convenient or ‘normal’ choice by the mother, and those around her; Formula feeding culture (−) | Capability – psychological |
Capability – physical | |
Opportunity – social | |
Motivation - reflective | |
Pressure to breastfeed from health professionals, family, friends and strangers in the antenatal and early post-natal period (−) | Capability – psychological |
Opportunity - social | |
Understanding of how to physically breastfeed (including latch and positioning) (+/−); physical challenges, including soreness, latch and tongue-tie (−); recovering from traumatic birth or C-section (−); support to overcome physical challenges from health professionals or others (+/−); hospitals have adequate/inadequate resources to support the initiation of breastfeeding (+/−) | Capability – psychological |
Capability – physical | |
Opportunity – social | |
Opportunity - environmental | |
Confidence in ability to breastfeed (+/−); inability to see how much milk baby is taking (−); belief in adequacy of milk supply (+/−); exposure to breastfeeding role models (+) or formula feeding role models (−); experience of formula feeding babies (−) | Capability – psychological |
Capability – physical | |
Opportunity - social | |
Belief that it is OK to breastfeed in public (+); Confidence to breastfeed in public (+/−); belief in ability to ‘discreetly’ breastfeed in public (+/−); knowledge of ‘safe’ places to breastfeed in public (+); confidence-building support from health professionals or others (+) | Capability – psychological |
Capability – physical | |
Opportunity – social | |
Opportunity - environmental | |
Partners and family encourage bottle feeding to ‘help’ with care (−) – expressing breastmilk for bottle feeding takes additional time and maternal energy (−); mothers desire/ability to reject formula feeding (+/−); belief breastfeeding takes extra time (−) and lack of support for household chores and caring responsibilities (−) | Opportunity – social |
Motivation – reflective | |
Capability – psychological | |
Breasts identified as sexual (−); Desire to stop breastfeeding to ‘get my body back’ (−) and quickly return to non-maternal activities/self identity (−) | Opportunity – social |
Motivation - reflective |
Remaining smoke free during pregnancy
“I was smoking I can’t remember if it was 15 or 20 a day and then I fell pregnant with [daughter], and that was the whole scare factor again. But I did agree with what (the health professionals) were saying so I switched to (an e-cigarette) when I was pregnant with [daughter] and I’ve been on them for two and half years at least” (Becky, e-cig user, ex-smoker)“But again that’s the sickness thing at the beginning (of pregnancy) and I wasn’t you know (smoking) comes hand in hand for me with drinking, or used to anyway…” (Hayley, abstinent, ex-smoker)
For some participants who smoked prior to pregnancy, stress reduced psychological capability to abstain from smoking:
“with (my most recent pregnancy)…towards the end, I had court with (my eldest daughter’s) father so seeing as I couldn’t drink, ok I did smoke five in a row because I was a bit stressed…” (Anna, abstinent; smoker during previous pregnancy)
“I smoke my e-cig and some people…might look at me and like judge” (Becky, e-cig user, ex-smoker)
“When I was pregnant with [youngest daughter] and [eldest daughter] I did smoke with them but it was in my own house, I never walked around out and about with one, it’s not the best look.” (Anna, abstinent; smoker during previous pregnancy)“My (car is my) bubble, I can cry, I can smoke, I can have a McDonalds in the car you know I can listen to music, I can do everything in the car.” (Jess, smoker)
“Even when I am not pregnant I don’t drink, I hate smoking, absolutely hate it. So yeah it’s never affected me because…I don’t miss it you know?” (Gaby, never smoked)“No I smoked, I smoked and then I quit and then I, when I found out I did quit but then I started smoking again when I was pregnant and then I went onto those e-cig fags and then I stopped on that but now I am pregnant again I’ve started having a few fags again it’s like I’ve got a craving for smoke or something, it’s really weird” (Cat, smoker)
Remaining abstinent from alcohol during pregnancy
“…the alcohol thing changes all the time doesn’t it? Like I think with (previous pregnancy) it was a no-no and I think now you can have one, they don’t recommend it obviously…” (Hayley, abstinent, drank alcohol during previous pregnancy)
“I have seen like things where babies have had problems because their mothers have been drinking alcohol and it’s like it’s not fair on the baby and it’s how it makes me feel, when you have a drink you feel, sometimes you feel like whoa and I don’t want to put a poor innocent baby through that really.” (Fiona, abstinent)
“I am sure, you can like (husband) has said oh I am sure it will be fine, just half a glass of wine.” (Donna, abstinent)“I did have one by the end of [baby son] you know I think it was around Christmas time I had a glass because [partner]s mum and my mum was like oh we had one with you, you’re this far gone.” (Hayley, abstinent, drank alcohol during previous pregnancy)
“I miss the social aspect of that obviously you can’t drink when you’re pregnant, you can’t do a lot of things when you’re pregnant (…) I miss going out because I didn’t drink a lot before I was pregnant but now it’s just like you know you can’t and….” (Jess, abstinent)“…in the end if my partner said anything I kind of just did the opposite just to you know prove a point, not, I wouldn’t go to the length that I would think that my baby is being harmed but just to make that point of you know that it’s nothing to do with you, this is my baby and my pregnancy. Because of Christmas we had I think it was champagne or wine or something and they were pouring it and my dad said: ‘Oh no, (Becky) can’t have any’, and I said: ‘Yes I can!’ [laughs]. I poured my share and made the point of drinking it all because it’s my baby and my pregnancy yeah. It irritates me so much when people say things like that because it’s not, and it’s men most of the time as well.” (Becky, drinks alcohol occasionally)
“You know it can’t be that good (for the baby)” (Hayley, abstinent, drank alcohol during previous pregnancy)
“I’ve had one or two drinks but some people they don’t mind drinking quite a lot when they’re pregnant but I don’t agree with that, I don’t mind having one or two, that can’t hurt you at all but I wouldn’t, I wouldn’t go over the limit do you know what I mean? I don’t agree with that but yeah I will have, I don’t do it often like…” Cat, drinks alcohol regularly)
“Oh I’d love one. (When we go on the hen night) It will kill me watching my mother with a bottle of wine, I’ll be there with my glass of coke [laughs]”. (Anna, drinks alcohol occasionally)
Exclusive breastfeeding for six months
“Because of the goodness that can go through and strengthen the immune system (in the first 2 weeks) isn’t it? I can’t remember what they call it now… Especially when you get to six months and you don’t have any nutrients from breast milk so technically you should introduce a bottle by then…” (Hayley, breastfed for three months previously; hopes to breastfeed)
“(I’m going to) bottle feed, yeah. I haven’t got the confidence to breastfeed. I am unsure really (if I’d like to try if I had the confidence), I lack confidence in that sort of thing so I would need confidence to do it but if I had the confidence I probably would give it a go.” (Fiona, attempted to breastfeed but early exclusive formula feeding previously; plans to formula feed)“I’m not one of them people anyway even like when you’re out and about and that, I’m just a shy person like that, I couldn’t imagine myself doing it outside, I haven’t got the guts to do it.” (Cat, formula fed previously; unsure whether to attempt to breastfeed)
“For the first two and half weeks you get, your boobs are so sore and you’re kind of just practising how to do it and they’re biting the wrong bits and sucking the wrong bit and then you get like bad blisters like all the way round and it’s so painful.” (Becky, combination fed previously; hopes to breastfeed)
“you’d be amazed what you can kind of get done [laughs] when you’re feeding a baby. Whereas actually when you’re feeding a baby with a bottle, the kind of, it’s quite difficult you can’t really do much and I found that I was quite tied to a sofa” (Donna, formula fed first child, exclusively breastfed second child, plans to breastfeed)
“my brother’s girlfriend now with my niece, she is breastfeeding and she said it’s you know it’s so easy, you get such a closer bond as well so I am really thinking about it this time around.” (Cat, formula fed previously; unsure whether to attempt to breastfeed)
“everyone has got an opinion on (breastfeeding in public) and it’s quite, quite interesting listening to people and they’re like: ‘I’ll do it anywhere’. I’m not that sort of person, I wouldn’t just do it anywhere, I’d feed them you know I don’t know if we were in a café or if we were in a restaurant or we’d gone to I don’t know in a park on a bench somewhere. So yeah I think I’d still be mindful of other people because I understand that some people don’t want to, they don’t want to see it or they think it’s not right, it should be something that’s done at home…” (Donna, formula fed first child, exclusively breastfed second child, plans to breastfeed)
“And this one I am just thinking I am just going to do straight to the bottle because I was in hospital for an extra two nights trying to breastfeed [baby son] and not one of them picked up on the tongue tie…” (Gaby, formula fed two previous children, breastfed third child for one month; plans to formula feed)
“I know (my husband) has got this system in place about feeding, how he will have the graveyard shift and I’ll have the rest of the day so I need to, in fact if it’s going to be breast obviously I’ve got to think about expressing and stuff like that. Like I said because he is going away (for work for a few months) you know the plan is at the moment him going away, I don’t have to worry about which it is.” (Jess, first child, plans to attempt to breastfeed)
“I was bottle fed and there is nothing wrong with me so that’s what is in my head, I don’t think it’s wrong either way.” (Hayley, breastfed for three months previously; hopes to breastfeed)
“…although sometimes now, (my daughter) is still tugging at my top and I’m like, (daughter), no, get off (laughs). I was like no, it got to the point I thought I need my body back now, this is it now, you can have your milk, you can have a bottle.” (Donna, formula fed first child, exclusively breastfed second child, plans to breastfeed)