In the theory of planned behaviour, subjective norms refer to the perceived social pressure that influences the individual to perform or not to perform a behaviour (Ajzen, 1991). The antenatal intention to exclusively breastfeed can also be affected by cultural acceptability. If
a behaviour is normalised or perceived as a “bad thing” or a “cultural taboo”, then this may
111
suggests that if a behavioural practices, such as breastfeeding, are a concern then it is important to evaluate the influence of injunctive social norms on that behaviour. Injunctive social norms are defined as the behaviours which are perceived as being approved of by other people in the wider society, these social norms have to power to influence intention, initiation and duration of exclusive breastfeeding, in a given society.
Research has shown the significant influence of social referents such as the husband, maternal grandmother, midwife, other family members and friends on the maternal intention to breastfeed (Adlina, Narimah, Hakimi, & Mazlin, 2006; Agunbiade & Ogunleye, 2012; Almroth et al., 2000; Arora et al., 2000b; Arts et al., 2010; Februhartanty, Bardosono, & Septiari, 2006; Fjeld et al., 2008; Ismail et al., 2013). Swanson and Power (2005), described
the subjective norms related to the breastfeeding practice as “normative beliefs” that can be
measured by recording the level of agreement or disagreement with the breastfeeding
opinions of five social referents taken from the woman’s social milieu such as the woman’s
partner, her own mother, her intimate friends, midwife and other people.
The normal method of infant feeding in Malaysia is mixed feeding or exclusive formula feeding (Adlina et al., 2006). In two studies in Malaysia (Adlina et al., 2006; Ismail et al., 2013) the researchers applied the theory of the planned behaviour to evaluate the association between antenatal intention and the performance of exclusive breastfeeding. While the mothers had strong antenatal intention to exclusively breastfeed, this intention did not translate into action. Their decision to stop exclusive breastfeeding was influenced by the imposition of injunctive normative beliefs. Significant others such as the husband, maternal grandmother, midwife and mother-in-law discouraged the new mothers from exclusively breastfeeding their babies (Adlina et al., 2006; Ismail et al., 2013).
112
A study conducted in Jakarta (Februhartanty et al., 2006), identified that the male partner56 or husband was the most important referent who advised the mother about exclusive breastfeeding before and after birth. In a study conducted in the USA (Arora et al., 2000b),
researchers found that significant others including the husband, maternal grandmother57,
other family members and friends were the main people who encouraged mothers to formula feed the baby. A lack of current knowledge about the benefits of exclusive breastfeeding in
the significant others’ opinions about infant feeding can be a major obstacle for the new mother who intends to breastfeed her baby exclusively (Agunbiade & Ogunleye, 2012; Almroth et al., 2000; Arora et al., 2000b; Arts et al., 2010).
In a study of mothers who were younger than 25 years old and had an antenatal intention to breastfeed their babies (Greenwood & Littlejohn, 2002), the researchers asked those mothers to participate in a comprehensive support programme. The program offered those young mothers prenatal education, counselling and housing support. While the researchers had an expectation that this group of younger mothers would have a shorter duration of breastfeeding, they had prolonged duration of breastfeeding due to the support program that they had during their pregnancy.
In a Scottish study (Swanson & Power, 2005), the theory of planned behaviour was
applied to assess the influence of the new mothers’ behavioural beliefs and subjective norms
on their intention to breastfeed. They found that subjective norms were the most influential factor on initiation and duration of breastfeeding. The breastfeeding mothers reported that
56 Male partner and male family members’ support will be discussed in chapter seven. 57 Grandmother and female family members’ support will be discussed in chapter six.
113
their close social referents offered them formula; however, their partners and midwife were the most significant source of support for their breastfeeding until six weeks after birth. The
researchers found that the new mothers’ perceptions of subjective norms would favour their
selected method of infant feeding. For example, the breastfeeding mothers perceived more social pressure to breastfeed, while the formula feeding mothers claimed that they experienced more social pressure to bottle feed (Swanson & Power, 2005).
The influence of subjective norms or social pressure on the mother’s intention to
breastfeed is heightened for first time mothers who do not have any previous experience of infant feeding as they may rely on the opinion of people who are around them for selecting the best method for infant feeding. First time mothers may also lack confidence in their decision to choose breastfeeding or to reject formula feeding (Swanson & Power, 2005). Therefore, subjective norms play an important role in supporting mothers who have no previous experience of breastfeeding (Cialdini, Reno, & Kallgren, 1990; Swanson & Power, 2005).
In the current research, Addison who exclusively breastfed her baby more than five months talked about how her family normalised breastfeeding to the extent that when she was pregnant for the first time she did not know that formula feeding could be an option.
Probably my family, I think – yeah – because my mum breastfed all of her kids I suppose I just assumed that’s what I would do yeah. I didn’t realise when I had my first son that women didn’t breastfeed. I suppose I was a little bit naïve. Because I hadn’t had children I didn’t realise that you could use bottles and formula and yeah so I just – yeah I assumed that everybody would start breastfeeding and that if they switched it was only because yeah they had to go to work or put the child into day care and they could no longer feed them. (Addison, February 2014)
114
Lucy who exclusively breastfed her baby for the full six months spoke about her mother who breastfed all of her four children including Lucy. She talked about her sister who educated her about breastfeeding indirectly by breastfeeding in front of her and showing her that breastfeeding is very easy to do. Lucy suggested that if her family members formula fed their babies, and formula feeding was a normal method of infant feeding in her family environment rather than breastfeeding, then instead of having a stated intention to exclusive breastfeed for six months she may have intended to formula feed her baby.
I knew my mum had done it with all four of us kids, my sister – she had a couple of kids by the time I had my first and she breastfed and made it look easy so I just – that’s what you do and yeah. I guess if we’d all been bottle-fed and stuff like that or formula I would have thought that was normal as well and maybe had gone that way, but because I’d seen breastfeeding around and that’s normal to me it was the way I wanted to go. (Lucy, April 2014)
Charlotte, who exclusively breastfed her baby for the whole six months talked about her
mother, partner and her partner’s family members who helped form her intention to
breastfeed exclusively. Charlotte regarded breastfeeding as a way to honour and remember her mother who had passed away when she was a child. She also spoke how her friends and educational background influenced her decision to exclusively breastfeed her baby as well.
Probably my mother even though she’s not here [her mother passed away] was really strong to have breastfeeding and she just was into natural things – yeah so she would have been really strong - and my partner and his family I suppose. But also I think maybe all of my friends – I can’t think of any who haven’t breastfed and they’ve all talked about how wonderful it is. It’s something we studied at Maori Studies when I was a student as well – songs and things that talked about breastfeeding and special relationships that you have with your child. But I think my mother would be the primary influence. (Charlotte, February 2014)
It is notable that most research participants in this current research were breastfed as a child which influenced individual attitudes towards breastfeeding. A systematic review
115
(Manno, Macdonald, & Knight, 2015) examined the relationship between breastfeeding behaviour in one generation and the intention, initiation and the duration of breastfeeding in the next generation. It showed the strong evidence for intergenerational continuity of breastfeeding practice, that having been breastfed as a child significantly related to the breastfeeding intention, initiation and duration of breastfeeding in the next generation (Manno et al., 2015). Having both sources of formal and informal support for breastfeeding from significant others was important and encouraged the maintenance of breastfeeding over an extended period of time. Therefore, health education around breastfeeding should target both primary and secondary social ties to encourage the prolonged duration of breastfeeding (Swanson & Power, 2005).
Hailey was a research participant in this study who had an antenatal intention to exclusively breastfeed her baby for six months. Following the birth of her baby Hailey breastfed exclusively until three months when breastfeeding was interrupted for 12 days due
to a medical condition that affected her baby. Once her baby’s health improved, Hailey
restarted fully breastfeeding until six months. Hailey had a lot of problems with breastfeeding because her baby was dairy intolerant and she had to remove all dairy products from her diet in order to produce dairy free breast milk for her baby. Although she encountered unforeseen barriers to breastfeeding after birth, Hailey was determined to initiate and sustain exclusive breastfeeding for her sick baby. She talked about the crucial support that she had from a friend who had successfully breastfed. She could not understand why some mothers gave up breastfeeding early when they were faced with a few problems.
116
To be honest, probably my friend who’s been there and done it, yeah. Just that it is possible if I tried really hard. Like, it’s not easy, but if I just keep trying even when it’s hard it’ll work out and then you’ll be pleased that you’ve pushed through that hard part. That it’s hard for a bit and then it becomes easy. And I think that is the case, that’s what it’s been like for me. Like, it was hard and I could see where people could just give up when it got a little bit hard, and then if you just keep trying it usually it gets better. (Hailey, February 2014)
In research on exclusive breastfeeding using the planned behaviour theory (Ismail et al., 2013), the importance of significant others on the mother’s intention to breastfeed exclusively was identified. It was recommended that for the promotion and support of exclusive breastfeeding behaviour significant others such as male partners and both maternal and paternal grandmothers should be encouraged to attend, and be included in, exclusive breastfeeding advocacy programs. Therefore, the information regarding exclusive breastfeeding support should be available in the community. They also suggested that up-to- date knowledge of health professionals related to exclusive breastfeeding should be promoted and that education related to exclusive breastfeeding should be individualised for each mother taking into account their socio-demographic characteristics and circumstances during the first six months after birth. For example, including additional information around the expressing and storing of breast milk for working mothers (Ismail et al., 2013).
It is demonstrated in several studies that women who practise breastfeeding place a greater emphasis on the influence of social supports on their intention to breastfeed compared to formula feeding mothers (Wambach, 1997). Khoury et al. (2005) applied the theory of planned behaviour to examine the relationship between intention and initiation of breastfeeding in a group of low-income mothers in the USA. They evaluated the influence of subjective norms and found that support from lactation consultants and hospital midwives was significantly related to initiation of breastfeeding in this group of mothers. Similarly, the
117
importance of social support in initiation and prolonged duration of intentional breastfeeding has been established in numerous studies with a positive benefit being observed in groups of mothers who are from socio-economic backgrounds that have statistically low-rates of breastfeeding (Hoddinott & Pill, 1999; Ingram, Cann, Peacock, & Potter, 2008; Ingram & Johnson, 2004; Khoury et al., 2005; Whelan & Lupton, 1998; Wilson et al., 2013). Amongst the all sources of social support, family support especially support from the male partner, maternal grandmother (Arlotti, Cottrell, Lee, & Curtin, 1998; Bezner Kerr, Dakishoni, Shumba, Msachi, & Chirwa, 2008; Emmott & Mace, 2015; Fisher, 2013; Furman, Killpack, Matthews, Davis, & O'Riordan, 2015; Giugliani et al., 1994; Grassley & Eschiti, 2008; Grassley et al., 2012; Ingram & Johnson, 2004; Khoury et al., 2005; Nickerson et al., 2012), health professionals ( Henderson & Redshaw, 2011; Khoury et al., 2005; Rayfield, Oakley, & Quigley, 2015; Renfrew et al., 2010) and peer support are strongly related to the prolonged duration of intentional breastfeeding behaviour (Arlotti et al., 1998; Dennis, 2003; Khoury et al., 2005; Nankunda et al., 2010; Stremler & Lovera, 2004).
Research has shown that antenatal intention to exclusively breastfeed is the most robust predictor of initiation and duration of exclusive breastfeeding (Behera & Kumar, 2015; Natan et al., 2015; Henderson & Redshaw, 2011). However, antenatal intention is insufficient for predicting behaviour if social support is lacking. Normalisation of breastfeeding within the family combined with peer support were the subjective norms that were identified by participants in this research that supported exclusive breastfeeding practice. Therefore, it can be concluded that the category of subjective norms is a critical variable in the performance of intentional behaviours (Göksen, 2002; Khoury et al., 2005). For example, initiation and prolonged duration of intentional exclusive breastfeeding behaviour is conditioned by
118
enabling influential factors such as family support, health professional support and the wider community support.