An Exploration of the Attitudes and Experiences of Mothers in the United Kingdom Who Chose to Breastfeed Exclusively for 6 Months Postpartum

Abstract

Background:

Levels of exclusive breastfeeding are negligible in the United Kingdom despite World Health Organization recommendations to practice exclusive breastfeeding for the first 6 months postpartum. Although numerous studies have explored the reasons behind low levels of breastfeeding, few have examined the behaviors of women who do breastfeed successfully. However, understanding the influences upon the decision to breastfeed exclusively is important in supporting women to continue breastfeeding.

Methods:

In the current study, 33 women with an infant 6–12 months old who exclusively breastfed for the first 6 months postpartum took part in an interview to explore their motivation and experiences while breastfeeding. The interview explored issues such as sources of support, difficulties, and familial and peer behavior.

Results:

Mothers reported high levels of confidence and determination in their decision despite difficulties in reaching their goal and discussed a range of techniques they adopted to overcome issues faced.

Conclusions:

Ingrained and strong beliefs that their choice of feeding method was the normal and healthiest way to feed an infant enabled mothers to overcome problems and continue breastfeeding.

Introduction

The World Health Organization recommends that infants be exclusively breastfed for the first 6 months of life.¹ Exclusive breastfeeding is defined as the infant receiving breastmilk only with no other liquids or solid foods. Exceptions are made for medicines and vitamin supplements.² Alongside the well-established benefits to infant and maternal health of breastfeeding over formula milk use,^3–7 exclusive compared with non-exclusive breastfeeding has been associated with a reduced risk of gastrointestinal disorders,³ respiratory disorders,⁸ and otitis media.⁹

Despite these recommendations, levels of exclusive breastfeeding for this period are extremely low. In the United Kingdom the recent Infant Feeding Survey (2007) recorded that less than 1% of mothers followed exclusive breastfeeding for 6 months postpartum: On the first day postpartum, 35% of infants had already received formula, and by 1 week postpartum only 45% of U.K. infants had exclusive breastfeeding status and by 6 weeks merely 21%.¹⁰ This pattern is reflected in other countries, including the United States.¹¹ Even in countries such as Ghana, where 99% of women initiate breastfeeding with an average breastfeeding duration of 22 months, only approximately 35% of infants are exclusively breastfed by 0–3 months, with only 6.4% at 6 months.¹²

A multitude of studies have examined why women do not initiate breastfeeding at birth or breastfeed for only a short duration. Numerous suggestions, interventions, and calls for greater support and funding have been identified.^13–17 There is, however, a dearth of research examining mothers who have successfully breastfed, in particular following guidance to breastfeed exclusively for 6 months postpartum. Studies that do explore exclusive breastfeeding often examine behavior over a shorter duration of time—for example, exclusive breastfeeding during the postnatal hospital stay¹⁸ or up to 12 weeks.^19,20 Many of these studies present data from interventions in developing countries.²¹

The aim of the current study was therefore to examine the attitudes and experiences of mothers who chose to follow World Health Organization guidelines and to breastfeed exclusively for 6 months. Through exploring the attitudes, experiences, and influences upon such women, a greater understanding may be gained of how to promote, increase, and support exclusive breastfeeding in the United Kingdom.

Subjects and Methods

Participants

Approval for this study was granted by a University Department of Psychology Research Ethics Committee. All applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research.

Thirty-three mothers with an infant 6–12 months of age who had exclusively breastfed for 6 months postpartum took part in a semistructured interview. Multiparous mothers were asked to complete the questionnaire in relation to their youngest child. Participants also provided infant birth weight and gestational age at birth.

Participants responded to posters or online participant requests asking for mothers who had breastfed their infant exclusively for 6 months postpartum. Posters were placed in day care centers, postnatal groups, and mother and baby groups in the City and County of Swansea, and information was posted on online internet-based parenting forums based in the United Kingdom (www.bounty.com; www.mumsnet.com; groups.yahoo.com/group/chatabm). As levels of exclusive breastfeeding in the United Kingdom are negligible,¹⁰ organizations such as breastfeeding support groups and online groups specifically aimed at longer-term breastfeeding and later introduction of complementary foods were targeted. Participants were also encouraged to recruit peers who had also exclusively breastfed. The community groups were, however, located in areas with varying degrees of social deprivation as measured by the Welsh Indices of Multiple Deprivation.²²

Measures

On responding to the study advertisements, participants were assessed for eligibility. Mothers only participated if they had breastfed for 6 months postpartum alongside giving no formula or complementary foods during this period. Exceptions were made for vitamin drops and medications. Eligible mothers took part in a semistructured interview to explore their attitudes and experiences of following this method. The interview explored themes such as attitudes toward breastfeeding, positive and negative experiences, familial and peer support, and professional advice and guidance. A copy of the interview schedule is showN in the Appendix.

Data analysis

A descriptive qualitative design was used.^23,24 Interviews carried out face to face or over the phone were recorded with consent by a sound recording device and transcribed. All identifying information was removed. A content analysis was performed for each transcript. This entailed reading through each transcript to identify emerging themes. Themes were grouped into key themes and subcategories. For example, one key theme was the impact of breastfeeding upon lifestyle. Data saturation principles were used with data collection continuing until it was felt that no new themes or ideas were emerging. Manuscripts were reviewed by a further two independent reviewers, and agreement upon coding was sought in greater than 90% of cases. The sample size exceeded recommended minimums.²⁵ Research subject identifiers are given after each quote describing subject age (in years), education (school, college, higher education), and occupational group (professional, skilled, unskilled, stay at home mother).

Findings

Mean age of the participants was 27.63 (SD 4.83) years, with a mean of 14.33 (SD 2.01) years of education. A range of participants completed the interview in terms of age, education, income, occupation, and marital status. Of the participants, 67.1% were primiparous. No significant difference was seen in mean age, years of education, or breastfeeding duration between mothers who were recruited online or through local groups.

Mothers discussed several influences, attitudes, and experiences associated with their decision to breastfeed exclusively. Key findings included the ideas that breastfeeding was the normal and healthiest way to feed an infant alongside a determination to overcome problems. Although mothers were supported by key family members, all mothers reported negative and confrontational experiences with others who felt that they should introduce formula milk or solid foods. Despite this, mothers were confident in their decision to breastfeed exclusively, discussing several ways to overcome these issues.

Decision to breastfeed exclusively is based on the most natural and healthiest option

Mothers discussed the factors that influenced their decision on how long to breastfeed and when to introduce formula or complementary foods to their infant. A belief that breastfeeding was the healthiest option for both infant and themselves was clear and drove breastfeeding duration. When asked directly, all mothers were aware of and agreed that they were following World Health Organization guidelines to breastfeed exclusively for 6 months and were able to list several benefits for both themselves and the infant to doing so, often citing scientific sources of information:

Lots of people gave me advice and suggestions about what I should do but I preferred to follow what the research suggested rather than one person's own experiences. (P1, 27, college, skilled)

However, mothers also mentioned other influences and personal beliefs as to why they chose this method. Breastfeeding was seen as the natural option. Mothers recalled how they saw breastfeeding as normal and expected behavior. They felt it was also the purest and healthiest option for their infant and considered it to be the default option rather than a choice:

It just seemed the natural route to follow. When my midwife asked me how I was going to feed I just thought “well of course I will breastfeed.” (P7, 29, higher education, professional)

I don't eat processed foods myself so why would I feed them to my baby? (P10, 30, higher education, skilled)

Perceiving exclusive breastfeeding as convenient, easy, and emotionally fulfilling

Alongside their reasons for choosing to breastfeed exclusively, participants reflected on their experiences of doing so. It was evident that mothers encountered a variety of experiences, both positive and negative, during this time. It is notable that every mother without exception reported that she enjoyed breastfeeding her baby. Benefits included finding breastfeeding to be a convenient way of feeding the infant and that it was easy and always readily available. Moreover, breastfeeding was also seen as an emotional relationship providing comfort and enjoyment for both mother and baby:

Call me lazy but once you start solids there's so much mess/time involved and feeding is more complicated so I've really enjoyed the ease and convenience of exclusively breastfeeding. (P16, 29, college, professional)

I enjoy breastfeeding him, it gives me a wonderful closeness and satisfaction. (P29, 35, higher education, professional)

Related to this were maternal perceptions surrounding the way breastfeeding exclusively made mothers feel. Emotions such as pride, achievement, and success were raised. However, these reactions were often tinged with disappointment that few mothers reached this target and sadness for those who had to stop breastfeeding before they had felt ready because of elements such as lack of support or pressure from others:

I feel proud of myself and pleased that my baby has had the best possible start in life. But I also feel sad that I feel proud—it should be the norm not the exception. (P2, 23, school, unskilled)

I feel quite proud of myself but it does also feel quite natural and right to me so I don't see it as a massive cause for celebration. (P17, 26, college, skilled)

Difficulties and challenges to be overcome, persevering through issues

Although mothers were adamant as to the benefit and need to breastfeed exclusively for 6 months and reported overall an enjoyable and convenient experience, few viewed their experience as entirely problem free. Many recalled issues that had to be overcome in order for them to continue doing so such as difficulties with latch and sore nipples and issues such as mastitis. It was not the case that mothers who had straightforward experiences breastfeeding were able to do so for 6 months exclusively. However, mothers reported a determination to overcome these issues due to their beliefs in the benefits of exclusive breastfeeding:

My son fed constantly all hours of the day and night. I suffered from mastitis four times, thrush in my breast tissue and internal bleeding in the milk ducts. It was a constant battle to keep feeding especially as others kept telling me to stop. (P26, 30, higher education, skilled)

As mothers approached the later stages of feeding, particularly around the 4-month mark, they often discussed feeling that problems were being pressed upon them by others. A common reaction was that the infant should be sleeping through the night by this stage and that failure to do so was attributed to the infant still being breastfed. This often led to them questioning themselves or feeling that they had to defend their decision, although they chose to persevere because of their beliefs about the superiority of breastmilk:

I felt a lot of pressure talking to others mums whose baby's were sleeping better than mine. Although I knew in my heart that formula or weaning was not the right option I felt guilty that I was doing the wrong thing and not getting my baby into a routine. (P30, 34, school, skilled)

Despite knowing the benefits of exclusive breastfeeding, mothers whose infant fed very frequently and did wake often in the night did admit to wondering whether weaning would reduce this and allow them to get more rest. However, mothers often reported that they persevered because they believed that their baby's need for exclusive breastmilk was superior to their need for sleep:

My baby woke 2–3 times a night between 4–6 months whilst I thought weaning might reduce this I did not want to wean because it was not to the health benefit of my baby. (P4, 26, school, stay at home mother)

Breastfeeding creates a closer mother–infant bond but at the same time makes life more baby-centric and sometimes limiting

A related theme to the difficulties of exclusive breastfeeding was the concept that following this method may impact on a mother's lifestyle and day-to-day routine. Some mothers felt that breastfeeding did not impinge on or affect their lifestyle substantially in any way, feeling that motherhood in general affects lifestyle and that their ideas of entertainment and enjoyment were now more baby-centric than before:

I have found my social life has changed anyway and I do things where babies/children are included and regularly meet other mums. I haven't wanted to leave either of my babies when they have been really young anyway except for the occasional trip to the hairdresser/dentist. (P18, 31, college, skilled)

Alternatively, mothers felt that having a breastfed infant did restrict their lifestyle. Issues such as being unable to leave their infant, go out in the evening, or drink alcohol were raised. However, this was viewed as such a short and important period in their infants' lives that it would soon be behind them but that the benefits to exclusive breastfeeding would be long term:

It has affected my social life as I cant go out in the evenings but I feel its for such a short period when looked at over a lifetime that it is worth the sacrifice to give her the best start in life possible. (P5, 28, school, stay at home mother)

Reactions of others can be both enabling and challenging

Alongside the issues mothers experience with the practicalities of exclusive breastfeeding, mothers were exposed to a wide range of both positive and negative responses and ideas regarding the method from those around them.

Support and encouragement reinforce beliefs that the right decision has been made

First, although the experiences of each mother varied, each knew at least one person close to her who had breastfed for an extended period of time. In the majority of cases this was either the woman's own mother or her partner's mother. Having this close contact was a source of support, information, and encouragement for the mother, including a feeling that she was acting in a “normal” way:

My family were always supportive, more than that, it was just regarded as the normal way to feed my baby. (P11, 33, higher education, professional)

It is notable that each woman also felt that her partner was fully supportive and encouraging of her choice to exclusively breastfeed, apart from one woman who felt she could have received more support. Partners helped out both practically with household tasks and emotionally, expressing pride and offering encouragement. It is important that partners were accepting of breastfeeding, seeing it as the normal and superior way of feeding an infant:

My husband was very supportive. He often tells me how proud he is. When it was hard at the start he did everything else for baby and in the house to allow me to concentrate on feeding and recovering from birth. (P22, 31, higher education, professional)

In addition, many women reported that they naturally appeared to become friends with other women following the same style of feeding as them either through contacts they made antenatally or through postnatal groups such as breastfeeding support groups:

I didn't really know anyone else who was doing this at first but over time through the peer support group and then through friends or friends I built up a group of us which was lovely because it was just so normal then. (P28, 28, college, stay at home mother)

Pressure from others to introduce formula or complementary foods can create difficulties

However, these positive experiences did not shield the mother from negative reactions from those close to them regarding their choice to exclusively breastfeed. Some of these comments were extremely negative, proffering embarrassment or disgust, but more common was the perception that although breastfeeding was good for a young infant, after a short period of time it was not needed or worth the effort of continuing to do so exclusively. Frequently mothers received comments that they were in some way denying or harming their baby through waiting until 6 months to introduce solid foods:

I have had many comments such as “you're not still breastfeeding are you?,” “Surely she's going to starve on just milk,” “I bet you have given her foods and just don't want to tell us” and “What a shame she can't have a biscuit/share in what others are eating.” (P14, 36, college, skilled)

Other people made comments implying I was mean making him wait despite the fact that he was obviously happy, healthy and gaining weight! (P31, 34, higher education, stay at home mother)

This type of reaction appeared to be related to the individual's own situation with breastfeeding and introducing solid foods. In particular, if the other mother had acted in a different way, the mother received negative comments as to her decision to exclusively breastfeed and was encouraged to follow the other woman's lead. These individuals often seemed to give examples to support their decision and try to convince the mother that their way would benefit both the infant and the mother herself. This was compounded by changes in the guidelines over time and the fact that previous generations often received different advice:

Friends seem very insistent that they are guidelines only and their baby just happened to be hungrier/bigger/more advanced. (P13, 24, college, stay at home mother)

There's a lot of talk of “my mum did this and it didn't harm me” or “I weaned my first at 17 weeks.” (P32, 26, school, unskilled)

Related to this, several mothers discussed feeling criticized or almost drawn into a race with other mothers who felt that early introduction of solid foods was indicative of infant development and ability:

I struggled with pressure mainly from other mums who introduced solid foods earlier. It started to feel like a bit of a race to see how quickly you could get the baby eating three meals a day. (P23, 31, school, stay at home mother)

Mothers show determination and initiative to overcome challenges

Mothers discussed a wide range of issues that they experienced in terms of other people's reactions, attitudes, and behavior toward their decision to exclusively breastfeed. Socially, mothers in this sample were in the minority, choosing to continue to breastfeed their infant when others were introducing formula milk and solid foods and encouraging or pressuring them to do the same. Mothers described a variety of approaches and techniques they adopted to resist these attempts to change their behavior, which centered on deliberately seeking companionship and social support from those who were supportive and encouraging of their choice. If they encountered negative attitudes from others, mothers were polite but firm in expressing their decision to breastfeed exclusively:

I deliberately surrounded myself with people who would support me. The last thing you need when you have been up half the night feeding the baby is someone telling you he needs something more or you haven't got enough milk. (P27, 36, higher education, professional)

In the end I used to just smile politely, say that I was going to carry on breastfeeding as that was the best decision for us and move the conversation on. (P23, 31, stay at home mother)

Occasionally this translated into changing their sources of support and seeing certain acquaintances less frequently. This was, however, seen to be worthwhile to ensure that they were part of a supportive environment:

One friend who did not breastfeed her children was very defensive about her decision and asked me not to feed my baby in front of her children in case they “asked questions.” I really didn't know what the answer was to that one and ended up avoiding her which was sad but my baby came first. (P19, 28, school, skilled)

This social circle importantly contained the woman's partner who was seen as an integral role in boosting her confidence and supporting her choices in front of others. Mothers described how although their partners often automatically supported their choices, they made certain that their partners were informed and openly supportive of their decision to others. Many reported how their partner would extol the benefits of breastfeeding to friends and family, supporting her choices:

It really helped to get my husband onside and understanding why it was important. He often tells his friends now why I am breastfeeding, how easy it is and how proud he is of me. (P33, 28, college, skilled)

Another way of ensuring that other people supported them was to suggest ways in which family and friends could get involved with the baby other than feeding. A common issue was that the baby breastfed very frequently and was naturally attached to the mother for this reason. Others found it hard to interact with the baby as they were used to associating feeding with love and care. Recognizing this, mothers often came up with ways in which others could care for the infant, giving them specific jobs such as bathing the baby, burping the baby, or looking after the mother herself:

My mother admitted that she was upset that she couldn't feed the baby and look after him for me. I said that the best way to help him was to ensure that I was looked after and she could really help by cooking meals or just sitting and keeping me company. Once she had a job and realised we really did need her she was much happier. (P24, 26, college, stay at home mother)

My partner did say he felt excluded but knew I was making the best decision for our baby. I suggested that he should be in charge of bath time and he relished the opportunity just to have that daddy daughter time with our little girl. (P8, 30, school, unskilled)

A common issue was other people not understanding the importance of exclusive breastfeeding, often because information had changed since they had looked after their own infant or not knowing the health benefits breastfeeding could bring. Mothers often specifically directed others to appropriate literature or talked about these benefits, finding that others then often became more supportive once they fully understood:

My partner likes science and facts and getting him to understand why I was doing what I was doing meant he was keen for me to carry on too. Personally I just think he liked not having to get up in the night like his friends though! (P21, 29, higher education, stay at home mother)

My mother did express a lot of surprise about how often he needed feeding and how I was on solids by now. I gave her a book about breastfeeding which she raised her eyebrows at but must as read as her attitude slowly started to change. (P18, 34, college, unskilled)

Finally, although mothers typically reported that they received support from friends or family, many still felt that others were unable to provide expert guidance because of lack of experience or were not fully understanding of their choices. Commonly, mothers described seeking specialist sources of advice and information in relation to exclusive breastfeeding. Online websites, including forums aimed at mothers who followed exclusive breastfeeding, specialist breastfeeding websites, and breastfeeding support networks, were commonly mentioned. Locally, mothers relied on breastfeeding support groups, breastfeeding counselors, and help lines and breastfeeding cafes:

I sought a lot of help and support from help lines, breastfeeding cafes and a friend and by 10 weeks it was easy and I never looked back. (P28, 28, college, stay at home mother)

All these sources of support appeared to enable mothers to continue breastfeeding in situations that may have otherwise challenged their reserve. Being surrounded by others who supported their decision or could offer practical advice and guidance helped mothers when facing situations such as breastfeeding in public, returning to work, or dealing with periods of exhaustion when the infant was feeding frequently:

I was really nervous at first about feeding her when we were out and about but in reality it was all a bit of an anticlimax! I took a friend or my husband with me the first few times so I didn't feel so vulnerable but in the end I just got on with it, did it discreetly and I'm not sure anyone even noticed really. (P29, 32, higher education, professional)

I got a bit anxious when it was time to start thinking about going back to work when she was five months old. I couldn't afford any more time off but wanted to keep feeding her. My local breastfeeding group were really supportive giving me practical tips, suggesting I talk to my boss about it and showing me it could be done. (P14, 39, college, skilled)

Sometimes the night times were just soul destroying when he was having a growth spurt. Just being able to have coffee with a friend and knowing she understood, had been doing the same and wasn't going to tell me that formula was the answer was a life saver. (P20, 34, higher education, professional)

In summary, mothers described a wide range of experiences and influences in relation to their decision to exclusively breastfeed. Although mothers generally felt supported by those closest to them and viewed their experiences as mainly positive, mothers were often exposed to quite considerable negative or challenging reactions from others who did not understand their choices. Despite this, mothers appeared determined to breastfeed exclusively and felt confident in their decision. They adopted approaches and techniques to ensure others around them supported and encouraged their decision. Mothers' inherent beliefs that breastfeeding was the natural, normal, and healthiest option for their infant and themselves fueled this.

Discussion

This study examines for the first time the experiences of mothers in the United Kingdom who have followed World Health Organization guidelines to breastfeed exclusively for 6 months postpartum.¹ In contrast to previous studies that have detailed the issues and difficulties mothers experience in relation to initiating or continuing breastfeeding,^13–17 it offers an important insight into the attitudes and experiences of mothers who have successfully breastfed.

Exploration of the attitudes and experiences of mothers who chose to exclusively breastfeed revealed several interesting themes. First, mothers who chose to follow exclusive breastfeeding appeared confident and determined in their decision. Following exclusive breastfeeding was viewed as the default choice, a normal behavior, with questions raised as to why others would choose differently. Mothers were highly informed in their decision, consulting expert and scientific sources rather than relying on the experiences and advice of others. High levels of confidence, knowledge, and determination have been associated with increased breastfeeding duration in several previous studies.^26–28 However, research has not examined this relationship as yet for exclusive breastfeeding. Mothers also reported high levels of support from family and peers. Many had a close relative who had also breastfed for a continued period of time. Again, these factors have been associated with a longer breastfeeding duration in other studies.^29,30 Mothers also described interactions with supportive and knowledgeable health professionals, which has been shown to be key to both breastfeeding initiation and duration¹⁵ and exclusive breastfeeding at 12 weeks postpartum.¹⁹ In general, it appears that the experiences described by mothers following exclusive breastfeeding echo those discussed by mothers who successfully breastfed for a longer duration of time, albeit not necessarily exclusively. Support, confidence, and a natural determination to breastfeed are clearly evident in both the findings of this study and those examining key influences upon breastfeeding duration.^31–33

Examination of the literature regarding formula use or a short duration of breastfeeding often points to mothers deciding to stop breastfeeding because of difficult experiences,³⁴ pain,³⁵ exhaustion,³³ or feeling overwhelmed by the frequency of feeding.³² Strikingly, in the current sample all mothers reported experiencing some level of difficulty in breastfeeding their infant, with many describing frequent and irregular feeding patterns leaving them feeling exhausted. Exclusive breastfeeding occurred despite these complications. Related to this point, although mothers reported feeling supported and encouraged by key family members to exclusively breastfeed, all mothers described incidents, often recurrent, where others were disparaging or unsupportive of their decision. Again, ridicule or a lack of support from others has been cited as a key influence upon breastfeeding cessation.¹³ In other studies pressure to introduce formula milk³⁶ or solid foods³⁷ have been described as reasons for an early cessation of breastfeeding or early introduction of complementary foods. Mothers in this sample, however, appeared to work through and overcome these problems in order to continue breastfeeding. The question therefore arises as to why some women continue breastfeeding through such difficulties, whereas others do not. The situation is likely to be complex. Perhaps increased levels of confidence, knowledge, and determination to breastfeed in this sample enabled them to work through the problems.

Typically studies show that women who are younger or who have lower levels of education are less likely to breastfeed.^10,11 Within the current sample mothers took part from a range of demographic backgrounds, including several younger mothers with lower levels of education. Examination of the data showed little difference in the attitudes and experiences of mothers within this subset of the sample compared with those older with higher levels of education who are usually associated with positive breastfeeding behavior. Despite their demographic circumstances these mothers appeared as informed, determined, and confident at their older peers. They faced challenges and suggestions that they should change their behavior from others, but they too were determined to overcome these barriers to continue breastfeeding exclusively. This reflects previous work in the area examining the experiences of younger mothers in the United Kingdom who breastfed for at least 6 months postpartum. These mothers reported attitudes and experiences associated with successful breastfeeding and described events and beliefs usually linked to those older and more highly educated mothers.²⁸ It appears that rather than demographic background directly influencing breastfeeding behavior, it is the attitudes and beliefs held by mothers that have a bigger impact. Mothers who hold positive attitudes and beliefs about breastfeeding appear to be better placed to overcome the effect of any negative circumstances in which they live.

The findings of the study are useful for those working in supporting mothers to breastfeed exclusively, particularly in relation to the approaches mothers implemented to overcome issues that they faced. Certainly mothers within this sample were determined to persevere through any issues experienced, adopting approaches to ensure they had the full support of others and looking to others for guidance and advice to overcome specific issues. Rather than difficulties leading to formula use, mothers deliberately sought to overcome these issues in a variety of insightful ways to ensure their ultimate goal of exclusive breastfeeding was achieved. These methods and ideas could be used in discussion with mothers as ways of overcoming difficult situations.

Further research needs to explore why specifically some women are able to follow exclusive breastfeeding, rather than perhaps choosing to breastfeed alongside formula or early introduction of solid foods. Much is understood of why women choose not to breastfeed, but not of the exclusive breastfeeding relationship. What leads a woman to continue breastfeeding but introduce formula supplementation or solid foods before 6 months? Conversely, what differences in perhaps experiences or attitudes encourage or enable a woman to breastfeed exclusively for this period? It would be interesting to examine in future research what factors are associated with a woman continuing to breastfeed through problems such as pain, perceived poor milk supply, or exhaustion or choosing to stop breastfeeding, either exclusively or completely. Why do mothers in this sample rise above this pressure and follow their own instincts and beliefs? Mothers in this sample appeared to display behaviors associated with positive deviance,³⁸ whereby they continued with the beneficial behavior of exclusive breastfeeding despite being in the minority and receiving criticism from others. What motivates and enables women to act in this way? Further detail is needed as to the background and situation of mothers who have successfully exclusively breastfed for 6 months or more.

There are several limitations to this study that could be addressed in future research. Participants were self-selecting, and this could have affected background and experience. However, because of low numbers of women choosing to exclusively breastfeed in the United Kingdom, it would be difficult to access large samples of women through local population-based samples. Use of the internet to recruit participants helped overcome this, allowing a large sample of women who breastfed exclusively for 6 months to be identified. Criticisms of internet-based recruitment suggest that older, more educated, middle class mothers are likely to use the internet and thus be notified of the study.³⁹ However, recent research has shown that levels of internet use for health related reasons is increasing,⁴⁰ with high numbers of pregnant and new mothers using the method to seek advice and support.⁴¹ The current sample was skewed toward those with a higher level of education, although this would be expected with the known relationship between breastfeeding and maternal education.¹⁰ However, within this group a wide range of demographic backgrounds were seen, and, as noted, little difference was seen in response between older, more educated mothers and their younger peers.

Limitations aside, this study provides insight into an area that has received little exploration. It offers an initial understanding to the experiences and influences upon mothers who choose to breastfeed exclusively that could be used to tailor support to increase levels of this behavior in the United Kingdom. Further research is now needed to provide greater understanding of the influences upon maternal decision to exclusively breastfeed for 6 months.

Footnotes

Disclosure Statement

No source of funding was received for this work. No competing financial interests exist.

Appendix

Table A1.

Semistructured Interview Schedule

1. Why did you decide to breastfeed exclusively for 6 months? Did you set out to do so deliberately?

2. What reasons were behind you choosing to introduce solid foods when you did?

3. Were you deliberately following Department of Health/World Health Organization guidelines?

4. Did you find it difficult to wait until 6 months to introduce solid foods? If you did, what did you struggle with?

5. What, if anything did you find easy about waiting until 6 months to introduce solids?

6. Did you ever worry that you were not doing the “right” thing and that your baby needed solid foods or formula?

7. How did being able to exclusively breastfeed your baby make you feel?

8. Do you think exclusively breastfeeding affected your lifestyle? For example, did it affect your ability to socialize or go back to work?

9. How have most of your friends and family fed their babies? Did they exclusively breastfeed?

10. Where did you get your information from about breastfeeding and weaning guidelines?

11. How did your partner (if applicable) feel about you exclusively breastfeeding? Were they supportive? What was his/her reaction?

12. How did your family feel about you exclusively breastfeeding? Were they supportive? What were their reactions?

13. How did your friends/other mothers feel about you exclusively breastfeeding? Were they supportive? What were their reactions?

14. What reactions if any did you get from health professionals (e.g., Doctor or Health Visitor) about exclusively breastfeeding?

15. What do you think general opinion is about breastfeeding exclusively until 6 months in the United Kingdom?

16. Figures from the latest U.K. Infant Feeding Survey showed that less than 1% of mothers exclusively breastfed. How does this make you feel?

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