CARRETILLAS ELEVADORAS Norma básica de emisión sonora.

Descriptive studies have identified many socio-demographic factors, such as those outlined above, associated with milk feeding decisions (Dennis, 2002; Scott & Binns, 1999). As outlined in Chapter 1, the milk feeding decision has been conceptualised as rational and a matter of individual choice, whereas it is likely to be a much more complex and multifaceted process (Sheehan et al., 2010). Milk feeding decisions can be influenced by many things, for example: culture; social circumstances; the family situation; health of the baby; and the health of the mother, her previous experience, other roles, and employment plans (Hoddinott et al., 2012; Kirkland & Fein, 2003; Murphy, 1999; O’Brien, Buikstra, Fallon, & Hegney, 2009). Studies have reported that women often ‘decide’ how they will milk feed their baby before conception or early in their pregnancy (Chambers & McInnes, 2006; Earle, 2002), and that this decision is unrelated to any promotion of breastfeeding by health professionals (Earle, 2002). Antenatal breastfeeding intention and postnatal behaviour are highly correlated (Chambers & McInnes, 2006) and women’s antenatal statements are often accurate predictors of whether or not they will initiate breastfeeding (Murphy, 1999). In addition, there is some evidence that those who decide to breastfeed before they are pregnant continue to breastfeed for longer than those who make the decision during pregnancy (Andrew & Harvey, 2011). So, what influences may affect a woman’s decision to breast or formula feed her baby initially, and to continue or cease breastfeeding?

It is clear that both women who choose to breastfeed and those who choose to formula feed have heard the ‘breast is best’ message (Andrew & Harvey, 2011; Burns, Schmied, Sheehan, & Fenwick, 2010; Hoddinott & Pill, 1999; Sheehan et al., 2010). Amongst breastfeeding mothers, the ‘breast is best’ mantra has been identified as influential in their decision to breastfeed (Andrew & Harvey, 2011; Burns et al., 2010). Women report deciding to breastfeed because it is ‘natural’ (Dykes, 2005), and good for the baby in terms of nutrition and immunity (Murphy, 1999; Dykes, 2005; Schmied, Sheehan, & Barclay, 2001). For some women the ‘breast is best’ message can be so powerful that they view formula feeding as second best (Murphy, 2000; Sheehan et al., 2010). It has also been suggested that ‘breast is best’ conveys to women that breastfeeding is the ‘right’ thing to do (Dykes, 2005; Sheehan et al., 2010). For many women, being a ‘good’ mother and breastfeeding are linked (Hauck & Irurita, 2003; Murphy, 2000; Schmied et al., 2001; Shakespeare, Blake, & Garcia, 2004). Therefore, not only can women feel pressured externally because of ‘breast is best’, they can put pressure on

themselves to breastfeed, or continue breastfeeding, because of it (Sheehan et al., 2010). However, some women have viewed the message as propaganda (Hoddinott et al., 2012), and even breastfeeding women have expressed distrust in it. Unsurprisingly, these women are less likely to continue breastfeeding (Andrew & Harvey, 2011).

Formula-feeding women are also usually aware of the ‘breast is best’ message (Hoddinott & Pill, 1999). However, formula-feeding mothers are more likely to question the benefits of breast milk: these mothers may listen to health professionals’ advice and consider it in the light of their own experience, rather than consider it fact (Andrew & Harvey, 2011). Some women who formula feed may feel a need to justify not breastfeeding (Andrew & Harvey, 2011), which can be achieved through expressing distrust in the message.

Dykes (2005; 2006) argues that despite the ‘breast is best’ message, the UK is a country with a predominantly bottle-feeding culture, although there are geographical variations. This has generated circumstances which impact on a woman’s milk feeding decision. For example, research has indicated that many adults and children have never seen a woman breastfeed (Dykes, 2006), and embarrassment or concern about breastfeeding in public are frequently articulated reasons not to commence breastfeeding (Andrew & Harvey, 2011; Dykes, 2006; McFadden & Toole, 2006). Hoddinott and Pill (1999) carried out a qualitative study with 21 women from the east end of London who were expecting their first baby. They concluded that women who had regularly seen a relative or friend breastfeed and described this positively were more committed to and confident about breastfeeding, although those who had only seen a stranger breastfeeding often described this as a negative experience. Hoddinott and Pill (1999) argued that positive experiences allowed mothers to accumulate ‘embodied knowledge’, that is knowledge gained through direct visual or practical experience of a skill such as breastfeeding. This was more important than theoretical knowledge, in this case knowing what the health advantages of breastfeeding were. More recent work has confirmed these findings. In a study of women in rural Scotland, Hoddinott, Kroll, Raja, and Lee (2010) found that of 259 pregnant women who had not breastfed before, those who reported seeing breastfeeding in the preceding 12 months were more likely to agree with the statement ‘It was lovely to see her breastfeed’ than those who had not. They concluded that positive attitudes to recently seen breastfeeding were more important determinants of feeding intention than age of first seeing breastfeeding,

the relationship of the person being seen and seeing breastfeeding in the media (Hoddinott et al., 2010). Finally, in another UK qualitative interview study of 12 women with babies aged seven to 13 weeks, Andrew and Harvey (2011) reported that those who had witnessed breastfeeding, or perceived breastfeeding to be the norm, breastfed for longer than those who had rarely seen breastfeeding.

Expectations of breastfeeding can also affect whether a woman breastfeeds and for how long. The idea of breastfeeding as ‘natural’ means that some women perceive it to be easy, and to think that if they really want to do it they will be able to (Sheehan et al., 2010). Antenatal preparation does not always provide an adequate picture of the difficulties that might be associated with breastfeeding (Burns et al., 2010; Hoddinott et al., 2012). In their qualitative study, Andrew & Harvey (2011) noted that their participants described breastfeeding as a skill that had to be learned, rather than the natural, easy process that some expected. Research has shown that women with realistic expectations are likely to breastfeed for longer than those with unrealistic expectations (Hauck & Irurita, 2003; Hegney, Fallon, & O’Brien, 2008). Other studies have indicated that, far from thinking it will be easy, many women lack confidence in their ability to breastfeed (Bailey, Pain, & Aarvold, 2004; Blyth et al., 2002; Hoddinott et al., 2012; Hoddinott & Pill, 1999). The importance of confidence has been demonstrated in a number of studies (Blyth et al., 2002) and a lack of confidence antenatally is associated with early cessation of breastfeeding (Ertem, Votto, & Leventhal, 2002). Previous experience is also important, and difficulties breastfeeding a first child can precipitate mothers to formula feed a second (Andrew & Harvey, 2011).

Family and personal circumstances also influence mothers’ milk feeding decisions. It has been demonstrated that an infant’s father and grandmother, particularly the maternal grandmother, are likely to be important influences in the decision to breast or formula feed (Andrew & Harvey, 2011; Reid, Schmied, & Beale, 2010). Stewart- Knox, Gardiner, and Wright (2003) identified having older children as a barrier to breastfeeding, as mothers with older children need to leave the home more often and as outlined many women have concerns about breastfeeding in public places. Some women choose to formula feed as they are planning to return to paid employment (Murphy, 1999). Earle (2002) found that women who wanted to maintain a strong personal identity after giving birth perceived breastfeeding as potentially damaging to this. For example, the time required for breastfeeding contributed to a feeling of loss of independence for some women in Andrew and

Harvey’s study (2011), which could be exacerbated if they are not able to go out easily because of anxieties related to feeding in public (Andrew & Harvey, 2011; Murphy, 1999).

Early cessation of breastfeeding is defined as stopping within three months of birth (Shakespeare et al., 2004). Socio-demographic factors associated with early cessation are very similar to those associated with not commencing breastfeeding, so younger women, women leaving education at 16 years or below, and white women have all been identified as likely to finish breastfeeding earlier than other groups (Avery, Duckett, Dodgson, Savik, & Henly, 1998; Hoddinott, Pill, & Hood, 2000). Postnatally, women’s confidence in their breastfeeding skills is as important as it is antenatally, and in an Australian study Blyth et al. (2002) demonstrated that maternal confidence was significantly associated with exclusive breastfeeding at one month and four months. However, many women continue to lack confidence in their ability to breastfeed, even after they have commenced doing so (Dykes, 2005) and a major reason given by women for the early cessation of breastfeeding is difficulties with carrying it out (Andrew & Harvey, 2011; Dennis, 2002; Hamlyn et al., 2002; Renfrew et al., 2005). The most commonly mentioned difficulty is perceived insufficient milk supply (Andrew & Harvey, 2011; Avery et al., 1998; Blyth et al., 2002; Dykes, 2005). Wright, Parkinson, and Drewett (2006) found an association between cessation of breastfeeding and frequent feeding, which could be linked to ideas of insufficient supply. Finally, just as in the initial decision to formula or breastfeed, family can have an impact on a woman’s decision to cease breastfeeding. In a Canadian study, Morse & Harrison (1987) found that amongst established breastfeeding mothers, the attitude of others such as partners, parents and friends changed over time, initially being supportive of the mother breastfeeding but becoming less supportive when the infant reached six+ months. They suggested that there was social coercion to discontinue breastfeeding based on cultural norms.

There is a vast literature about supporting women who wish to breastfeed, or are doing so, but this is beyond the scope of this review. However, of relevance to this study is how women’s relationships with health professionals develop during this early period. Briefly, according to Burns et al. (2010), in Western societies breastfeeding knowledge is delivered principally by health professionals (Burns et al., 2010). However, it has been demonstrated that professional knowledge and support are not always viewed positively by women, who complain about receiving incorrect or conflicting advice (Britton, McCormick, Renfrew, Wade, & King, 2007;

Dykes, 2006; McFadden & Toole, 2006; McInnes & Chambers, 2008). It has been suggested that health practitioners are ill-prepared to support breastfeeding women (McFadden, Renfrew, Dykes, & Burt, 2006) and that there is inadequate integration of embodied, vicarious, practice-based and formal knowledge in strategies to equip practitioners with the education they require to do so (Dykes, 2006). Peer support is sometimes favoured by women, because of the use of lay language and practical suggestions (Britton et al., 2007; McInnes & Chambers, 2008). However, social support may be undermining if there is a lack of breastfeeding knowledge or experience within the social group (McInnes & Chambers, 2008).