In chapter four the influence of antenatal intention on six months exclusive breastfeeding behaviour is discussed. The theory of planned behaviour is applied as a framework to support the findings. The chapter reviews the relevant literature and uses extracts from participant interviews to explore emerging themes related to the theory of planned behaviour. This theory is extended to include self-identity as a useful variable that enhances understanding of intention and performance of six months exclusive breastfeeding practice.
Chapter 5
This chapter considers reasons for stopping breastfeeding exclusively and starting solids or formula for babies between three and six months. The chapter reviews international and national literature related to the reasons for giving up exclusive breastfeeding or starting solids earlier than six months. It considers why promoting six months exclusive breastfeeding should be a priority for the government. The six months exclusive breastfeeding recommendations as a general health policy and returning to work as an influential factor on exclusive breastfeeding duration are considered. The emerging themes are discussed using examples from the interviews.
Chapter 6 and chapter 7
Chapter six and chapter seven focus on the importance of social support from family members. The theory of stress, coping strategies and social support proposed by Thoits (1995), is applied to interpret the findings related to family support in these two chapters.
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The importance of social support for improving physical and mental health and the importance of support from significant others, similar others and similar significant others as well as different types of social support are discussed in the sixth chapter. Chapter six is about the importance of family culture for breastfeeding. The chapter explores support from grandmothers and other female family members such as sisters and female in-laws. The
emerging themes in this chapter are discussed using examples from the participants’
narratives and an overall conclusion outlined.
Chapter seven continues with themes related to stress and coping through exploring the importance of support from male family members for exclusive breastfeeding initiation and duration. The transition to fatherhood, the importance of breastfeeding education for fathers and cultural views that discourage men to support breastfeeding are considered. Findings related to the breastfeeding support from male family members are discussed using extracts from the interviews to illustrate.
Chapter 8
This chapter considers the importance of health professional support for successful exclusive breastfeeding practice. The chapter reviews the literature related to health
professional support for initiation and duration of exclusive breastfeeding. Michel Foucault’s
theories of governmentality and bio-power are applied to interpret themes related to mothers’
resistance to breastfeeding as a result of feeling pressured within the New Zealand health system. The emerging themes, as well as discussion related to health professional support using examples from the participants' narratives, are explored.
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This chapter considers the kinds of breastfeeding support that participants accessed from the Internet including health-focused websites, online forums, smartphone apps and social network platforms. The chapter describes the importance of social media and the Internet for
“Generation Y” mothers and the importance of Skype and Facebook for promoting
breastfeeding in the digital age. Ideas relating to the “strength of weak ties” and “landscapes of care” are applied to illuminate the findings of this chapter related to breastfeeding support
through social media. The emerging themes and discussion associated with breastfeeding
support through social media as well as the extracts from the participants’ narratives are outlined.
Chapter 10
Chapter ten presents the thesis conclusions, the research limitations, implications for practice, and suggestions for future research. In addition, the concluding chapter offers a summary of the thesis as well as the strengths of the current research. Chapter ten also identifies six months exclusive breastfeeding as a relational health behaviour which is socially constructed and influenced by actual and virtual social networks in which the mother, family members and health professionals are embedded.
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Chapter 2: Literature Review
Introduction
In the previous chapter, the importance of six months exclusive breastfeeding for public health and an overview of the research study was provided. This chapter reviews the New Zealand and international literature related to the importance of six months exclusive breastfeeding, as well as the influence of antenatal intention, and formal and informal social support on six months exclusive breastfeeding practice. The literature related to reasons for stopping exclusive breastfeeding between three and six months is reviewed. Data bases searched through the Massey University Library website for this literature review included Web of Science, PubMed, Cochrane Library and Newztext Plus (Newspaper database that includes Index New Zealand) as well as Google Scholar. Key words used include breastfeeding intention, exclusive breastfeeding duration, breastfeeding support and breastfeeding support through social media.
The importance of six months exclusive breastfeeding
Breast milk is an ideal source of nutrition for the development of infants as it contains
many health benefits for both mother and baby (Ip et al., 2007).According to the fact sheet
Number 342 of WHO 2014 about infant feeding that was updated in January 2016 (WHO, 2014b) every child has the right to optimal nutrition based on the Rights of the Child.
The American Academy of Paediatrics (AAP) recommends breastfeeding as breast milk
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human breast milk incomparable for infant nutrition (Gartner et al., 2005, p. 496). Breastfeeding also provides essential nutritional substances that are necessary for the first six months of life. It has anti-inflammatory and immunological qualities that protect infants against common childhood infections and diseases (Lawrence & Lawrence, 2010) as well as long chain polyunsaturated fatty acids that are necessary for the development of the nervous system (Innis, 2003).
In 2007, researchers reviewed 400 individual pieces of research related to the influence of breastfeeding on short and long-term neonatal and maternal health outcomes in developed countries and they concluded that breastfeeding reduced the neonatal risk of acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, obesity, diabetes types 1 and 2, childhood leukemia, sudden infant death syndrome and necrotizing enterocolitis (Ip et al., 2007).
For maternal outcomes, a history of breastfeeding was related to a reduction in the risk of ovarian and breast cancers (Ip et al., 2007). Several studies, for example, including the Collaborative Group on Hormonal Factors in Breast Cancer (2002) stated that the incidence of breast cancer was higher among women who had never breastfed (Bernier, Plu-Bureau, Bossard, Ayzac, & Thalabard, 2000; Ip et al., 2007). Similarly, the rate of ovarian cancer in mothers who had never breastfed was found to be 27% higher than for those who had
breastfed even for a short period (Ip et al., 2007). Research also has shown early weaning
and never breastfeeding is related to an increased risk of maternal postpartum depression (Ip et al., 2007). In a study of 209 women in the USA using the Edinburgh Postnatal Depression Scale a score of 13 or higher which is indicative of probable postpartum depression,
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significant risk factors for postpartum depression were associated with not breastfeeding, a history of depression and cigarette smoking (McCoy, Beal, Shipman, Payton, & Watson, 2006).
As mentioned earlier, breast milk contains antibodies which protect children against common childhood diseases. For example, pneumonia and diarrhoea are the two primary fatal diseases for children around the world that can be prevented through six months exclusive breastfeeding (Bachrach, Schwarz, & Bachrach, 2003; Ip et al., 2007). Apart from the health benefits of breastfeeding, there are many other advantages of breastfeeding such as it is ready to use, it is convenient and cheaper than formula (McIntyre, Hiller, & Turnbull, 2001; Thompson, 2005). Furthermore, not only does breast milk provide immediate health benefits for the baby, but it also improves their adulthood quality of life as people who were breastfed as children are less likely to be obese or get diabetes type II, and they also perform better in intelligence tests (Bernier et al., 2000; Ip et al., 2007; WHO, 2015). Breastfeeding is the most important factor for the physical health of the mother and baby and contributes to the social and emotional well-being of the whole family (World Health Organization, 2003). Consequently, WHO (2003) recommends a hierarchy for infant feeding: 1. Breastfeeding by the mother of the baby, 2. Feeding with the expressed breast milk from the mother of baby, 3. Feeding with breast milk from another woman (donor milk), 4. Feeding with powdered infant formula (least favoured).
In comparison with formula feeding, breastfeeding has many advantages. Formula fed infants, compared to breastfeeding children, are more likely to be admitted to primary health care institutions or hospitals for nutrition-related health problems which can contribute to
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additional costs to the health system of a country (Cattaneo & Quintero-Romero, 2006). More specifically, the Breastfeeding Trends and Updated National Health Report identified that there was a significant relationship between lower risk of early-life diseases and breastfeeding. For instance, the incidence of acute otitis media among infants who were fully formula fed was 100% more than for those who were exclusively breastfed for the first six months of life (Ip et al., 2007). Furthermore, the rate of lower respiratory tract infections in the first year of life was 250% higher for infants who were formula fed in comparison with infants who were exclusively breastfed (Bachrach et al., 2003). It is important to note that the lack of breastfeeding particularly exclusive breastfeeding has a life-long effect on infants and children such as impaired social and cognitive development or poor school performance (WHO, 2003).
According to WHO (2003), exclusive breastfeeding should be maintained for the first six
months for every child. “Exclusive breastfeeding” has the following characteristics: 1. the
baby has received only breast milk, no water, no formula and no other liquid or solids, 2. allows the infant to receive drops and syrups (vitamins, minerals, and medicines). The WHO recommends that all babies who are breastfed exclusively for the first six months of their life should be breastfed with appropriate complementary food after six months and into their second year and beyond (WHO, 2003). Solid food can be introduced in the form of mashed fruits and vegetables after six months as they will provide a perfect complement to breast milk (Gartner et al., 2005; WHO, 2015).
Besides the health benefits of prolonged exclusive breastfeeding for mother and baby, there are many economic advantages of exclusive breastfeeding for six months as well. According to the WHO (2016), the rate of any breastfeeding is very low worldwide, for
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example, less than one in five babies are breastfed during the first year of their lives in developed countries, and only two in three infants receive any breast milk between six months and two years in developing countries. As a result of this low rate of breastfeeding around the world, the global economy lost more than 300 billion US dollars in 2012 (WHO, 2016). If the rate of six months of exclusive breastfeeding duration increases to at least 90% in countries such as the US, China and Brazil and 45% in the UK, these countries would save $2.45 billion, $223.6 million, $6 million, $29.5 million respectively in their healthcare systems due to the cutting treatment costs of common childhood diseases such as diarrhoea, asthma and pneumonia, that can be prevented easily by exclusive breastfeeding. Therefore, lower rates of optimal breastfeeding have an adverse impact on the economy of both high and low-income countries in the world (WHO, 2016). The health and economic benefits of breastfeeding have become particularly salient for developed countries as the middle classes experience downward social mobility and poverty rates increase (Piketty, 1995; Standing, 2011). As it has been mentioned earlier, since breastfeeding improves child development, increases IQ and the performance of children at school, and this then increases the chance of having a high earning job in adulthood. Therefore, the benefits of breastfeeding will improve the economic gains for every family as well as the impact on the national economy (WHO, 2014b).
Although six months exclusive breastfeeding is the optimal method of infant feeding that is recommended by WHO and other health organisations (Ministry of Health, 2009; Paediatrics, 2005; WHO, 2015) the rate of six months exclusive breastfeeding is very low globally (Ahlqvist-Bjorkroth et al., 2016), as the introduction of solids or liquids before six
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Remmington, & Remmington, 2011). For example, the rate of exclusive breastfeeding is around 38% globally, and this low rate of exclusive breastfeeding has not changed in about 20 years (WHO, 2016). Therefore, increasing the rate of six months exclusive breastfeeding to at least 50% by 2025 has become the global health target (WHO, 2016). Even though the
full six months duration of exclusive breastfeeding is the preferable recommendation, “any
breastfeeding is valuable”13 should be considered as well. For example, research shows
health professionals should still encourage mothers to breastfeed their babies for six months exclusively. However, partial breastfeeding is also valuable containing many health advantages for both mother and baby compared to no breastfeeding (Agostoni et al., 2009; Inoue & Binns, 2014).
Breastfeeding in New Zealand
In 1991, New Zealand was a signatory to the Baby-Friendly Hospital Initiative (BFHI) convention which was launched (WHO & UNICEF, 2009) after the International Innocenti Declaration of 1990 on the Promotion, Protection and Support of Breastfeeding in Florence, Italy (Declaration, 1990). In New Zealand, the New Zealand Breastfeeding Alliance (NZBA) is contracted by the Ministry of Health to promote, protect and support breastfeeding (Ministry of Health, 2016; NZBA, 2016). The NZBA as a national authority is responsible for the implementation of BFHI and Baby Friendly Community Initiative (BFCI) and
13Any breastfeeding includes Exclusive Breastfeeding (no other liquid or solid and just breastfeeding), Almost Exclusive Breastfeeding (breast milk only, but occasional tastes of traditional foods or other liquids), Full Breastfeeding (almost exclusive and exclusive breastfeeding), and Partial Breastfeeding (or Mixed Feeding: the infant receives breastfeeding plus breast milk, non-human milk, other liquids and solid foods) (Labbok, 2000).
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provides support in the form of training, research, accreditation services and essential breastfeeding knowledge for both health professionals and maternity services to implement best practice related to breastfeeding (NZBA, 2016). In 2000, following financing the NZBA to develop the BFHI accreditation program, the number of baby-friendly maternity facilities in New Zealand increased dramatically from zero in 2000 to almost 96% in 2011(NZBA, 2016). At the same time, the rate of exclusive breastfeeding at discharge increased sharply from around 55% in 2000 to approximately 85% in 2011 (Martis & Stufkens, 2013). In 2014, 96% of the hospitals were baby friendly in New Zealand which means their staff are trained to have the up to date knowledge of breastfeeding as well as how to support mothers to breastfeed their newborns successfully. Previously health care professionals in hospitals often gave babies formula particularly before the implementation of the baby friendly hospitals in New Zealand. However, today in very rare cases, and just for medical reasons, the hospital staff may supplement breast milk with formula.
It is important to note that in New Zealand, another reason for the successful increase of exclusive breastfeeding rates at discharge is the significant breastfeeding support from health professionals such as New Zealand registered midwives who work in the community. For instance, most New Zealand women have a midwife as their Lead Maternity Carer (LMC). In the majority of cases, the midwife visits the mother from early pregnancy until six weeks postpartum. It is also highly likely that the baby will be placed skin to skin and breastfed immediately after birth with the midwife providing breastfeeding support until six weeks postpartum.
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New Zealand data have shown that the rate of six months exclusive breastfeeding is still very low and the maintenance of exclusive breastfeeding between three and six months is a major challenge for the New Zealand maternity system. For example, in 2014, 42% of infants in New Zealand were breastfed exclusively at three months, but only 16% of them breastfed exclusively at six months (WHO, 2014a).
Many influencing factors can positively or negatively impact on the intention, initiation and maintenance of six months exclusive breastfeeding such as significant others, health professionals, community and culture (Dodgson, Duckett, Garwick, & Graham, 2002). New Zealand is a bicultural country due to the signing of the Treaty of Waitangi between Maori and the British Crown. New Zealand also is a multicultural nation due to high levels of immigration from around the world (New Zealand in Profile, 2015). Different cultures have their own traditions, beliefs and values which influence their infant feeding practices. Therefore, understanding the sociocultural influences that support or impede exclusive breastfeeding for six months in New Zealand is also required to address the low rate of exclusive breastfeeding at six months. For example, according to an analysis of 2004-2009
breastfeeding data of babies examined by Plunket14 (Plunket, 2010), there are large
differences in breastfeeding rates by ethnic groups and regions in New Zealand. Exclusive breastfeeding patterns for 2-5 weeks, 6-9 weeks, 10-15 weeks and 16 weeks to 7 months amongst four categories of Maori, Pacific, Asian and other (other ethnic groups) were examined. It was found that Pacifica mothers had the lowest rate of exclusive breastfeeding,
14 In New Zealand, Plunket nurses are well child providers and practise in the community providing home-
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followed by Maori and Asian. Regionally the lowest rate of exclusive breastfeeding through
all age groups was in Counties Manukau15, while Northland16 had the highest rate of
exclusive breastfeeding (Figure 2.1.). A limitation of the study identified by the authors was that as Plunket does not provide support to all infants in New Zealand data from approximately 10% of newborns was missing (Plunket, 2010). Similarly, the findings of a study (Abel, Park, Tipene-Leach, Finau, & Lennan, 2001), based on 150 participants from Maori, Pakeha (European), Samoan, Cook Islands, Niuean and Tongan ethnic groups, residing in Auckland, New Zealand showed similarities across all ethnic groups in the realized importance of breastfeeding, and in the provision of support and advice during pregnancy and postpartum. However, there were some differences between ethnic groups based on the source of support. Amongst all of the Maori and Pacific groups, family support was important including support from the husband/male partner during the pregnancy as well as support from the maternal grandmother and other female family members after the birth in the provision of infant care.
In contrast, support from a health professional was the most important source of support for the few Maori and New Zealand-raised Pacifica participants who did not have a strong family network available. The sources of support for Pakeha mothers were different to those
15 Counties Manukau has a much higher proportion of Pacific Island people, a younger population and
proportionally more people in the most deprived section of the population in comparison to the national average. Retrieved from:http://www.health.govt.nz/new-zealand-health-system/my-dhb/counties- manukau-dhb/population-counties-manukau-dhb . Accessed date: 20/01/2017
16 Northland has a much higher proportion of Maori, lower proportion of Pacific and an older population
significantly in comparison to the national average. In addition, Northland has a very high proportion of people in the most deprived section of the population, whilst the least deprived section is under-
represented compared to the whole New Zealand average. Retrived from:http://www.health.govt.nz/new-