Breastfeeding Attitudes Among Couples Planning Exclusive Breastfeeding or Mixed Feeding

Introduction

For the multitude of benefits that breastfeeding provides to infants and mothers, the American Academy of Pediatrics ¹ and the American Dietetic Association ² strongly endorse breastfeeding for the first year of life. Because breastmilk is uniquely suited to the needs of the human infant, standards for growth, health, and development are based on healthy breastfed infants. ¹ The majority of infants in the United States are breastfed at birth (74%), but nearly one-fourth of breastfed newborns are supplemented with formula (24%) in the first 2 days of life. ³

Breastfeeding initiation is influenced by several factors, including age, education, race/ethnicity, and social support.^3–5 Typically, both age and education are positively associated with breastfeeding. According to data from the National Immunization Survey for infants born in 2006, women 30 years of age and older are more likely to breastfeed (78%) than teenagers (56%). ³ Similarly, significantly higher breastfeeding rates are observed among women with a college degree (86%) compared with those who have not completed high school (68%). ³ Race and ethnicity also play a role in the infant feeding decision. Nationally, the highest rates of breastfeeding initiation are reported in Asians or Pacific Islanders (83%) and in those of Hispanic or Latino ethnicity (82%), whereas the lowest rate is observed in blacks (60%). ³ Social support, which can promote or discourage breastfeeding, is provided by healthcare providers, husband/partner, family, and friends.^4,6–10 The relative effect of these individuals on the decision to breastfeed varies among populations; however, husbands/partners are cited as powerful members of the support network within most groups.^{4,6,7,9,11,12}

Several studies have explored the role of husbands/partners in women's infant feeding choices. In a study designed to describe factors influencing the infant feeding decision among primarily white mothers at a family medicine practice in Pennsylvania, 37% of formula-feeding mothers identified the father's feelings as a contributing factor in the decision to formula feed. ¹³ Furthermore, 80% of these mothers indicated that paternal support would have encouraged them to breastfeed. In a prenatal survey of predominantly black primiparas at an inner city university hospital, women who reported paternal support for breastfeeding were 20 times more likely to describe plans to breastfeed than those without paternal support. ¹⁴ A study of Australian women in the early postpartum period noted similar trends: Mothers who received breastfeeding support from the infant's father were nine times more likely to breastfeed at hospital discharge than mothers without support. ¹⁵ In an analysis of data from the 2007 Behavioral Risk Factor Surveillance System in Texas, fathers' attitudes were related to infant feeding choice; specifically, favorable paternal attitudes about breastfeeding images in the media and accommodations for breastfeeding women in the workplace were associated with increased likelihood of choosing breastfeeding over formula feeding. ¹⁶ The results of these studies suggest that fathers have the potential to dramatically impact the infant feeding decision.

Traditionally, the infant feeding method is categorized as either breastfeeding or formula feeding. However, a third option exists—feeding a mix of breastmilk and formula.^17–20 Because the timing and circumstances surrounding the decision to mixed feed are varied—from a carefully considered prenatal intent to a rapid response to unexpected events after birth—this feeding method has not been well characterized in the literature. The goal of the current study was to describe attitudes toward breastfeeding among couples planning exclusive breastfeeding or mixed feeding.

Subjects and Methods

The current article is the first report from a larger study exploring breastfeeding attitudes, breastfeeding confidence, and infant feeding outcomes. Subjects were recruited from outpatient clinics in the Midwest via information/screening forms. To be eligible for inclusion, participants had to meet the following criteria: pregnant, partner/spouse willing to participate, intention to breastfeed, and no previous breastfeeding experience. The Ball State University's Institutional Review Board approved the protocol, and all participants gave informed consent prior to study entry. Eligible individuals enrolled in the study at any point during pregnancy, but completed surveys only during the third trimester.

The survey instruments—one for expectant mothers and one for expectant fathers—were originally developed by Freed et al. ²¹ to assess demographic characteristics and breastfeeding attitudes. Both versions of the survey asked subjects to describe their agreement with a series of attitudinal statements using a 5-point Likert scale, with 1 indicating greatest agreement and 5 indicating greatest disagreement. In addition, the version given to expectant mothers also included statements for prediction of expectant fathers' attitudes. Subjects were instructed to complete the surveys without input from their spouses/partners and to return them within 1 month or by the infant's due date, whichever was earlier.

Several terms were used to describe and/or categorize variables during the analysis of data and in the reporting of results. “Maternal” and “mother” referred to the infant's mother. “Paternal” and “father” referred to the infant's father. “Exclusive breastfeeding” described feeding the infant breastmilk only, with no other liquids or solids given for nourishment. “Mixed feeding” described feeding the infant both breastmilk and formula.

Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, IL). An a priori power analysis, with α=0.05 and 1 – β=0.8, indicated a sample size of 64 was adequate to detect a medium difference (0.5) in the larger study's primary outcome, continuation of breastfeeding at 1 month postpartum. Collected data were nominal or ordinal in nature; as a result, nonparametric tests were chosen for statistical analysis. ²² Associations between planned infant feeding method and demographic variables were described using χ² analysis. Attitudinal differences between couples planning to exclusively breastfeed and those planning to mix feed were assessed by Wilcoxon's rank-sum tests. Differences between mothers' and fathers' responses to the attitudinal statements and between mothers' predictions of fathers' responses and fathers' actual responses were evaluated by Wilcoxon's signed-rank tests. The level of significance was set at p<0.05.

Results

In total, 71 couples were recruited. All returned completed surveys within the requested time frame. Demographic characteristics of the sample are summarized in Table 1. The majority of subjects were white (85% of mothers and 76% of fathers), at least 25 years old (58% of mothers and 69% of fathers), educated beyond high school (70% of mothers and 68% of fathers), and married (72% per mother's report). Most mothers planned to exclusively breastfeed (79%); the remainder planned to mix feed. In a comparison of demographic characteristics by planned feeding method, couples intending mixed feeding were significantly more likely than those intending exclusive breastfeeding to report paternal age as less than 25 years (p=0.019), maternal age as less than 25 years (p=0.006), maternal education as high school diploma/GED or less (p=0.023), and marital status as unmarried (p=0.001).

Maternal and paternal attitudes toward breastfeeding are described in Table 2. Participants most frequently indicated that breastfeeding was better for infants (100% of mothers and 93% of fathers), was natural (99% of mothers and 89% of fathers), helped mothers feel closer to their infants (96% of mothers and 89% of fathers), and protected infants from diseases (97% of mothers and 86% of fathers). There were several attitudinal differences between mothers and fathers. Compared with fathers, mothers responded more strongly that breastfeeding was natural (p=0.011), was better for infants (p=0.038), helped mothers feel closer to their infants (p=0.012), protected infants from diseases (p=0.004), was not harmful to breasts (p<0.001), and did not make breasts unattractive (p=0.031). Mothers also reported greater respect for breastfeeding women (p=0.042) and were more interested in additional information about breastfeeding (p<0.001) than their husbands/partners. Mothers' predictions of fathers' attitudes were not significantly different from fathers' reported attitudes for seven of the 12 survey items. However, fathers were more likely to indicate that breastfeeding was harmful to breasts (p=0.043) and made breasts unattractive (p=0.041) than predicted by mothers. Compared with mothers' predictions, fathers were also more likely to report respect for breastfeeding women (p=0.042), to indicate that breastfeeding helped mothers feel closer to infants (p=0.024), and to describe breastfeeding as the purpose of breasts (p=0.007).

Breastfeeding attitudes varied between parents planning exclusive breastfeeding and those planning mixed feeding. Tables 3 and 4 describe attitudes toward breastfeeding by planned feeding method in fathers and mothers, respectively. Compared with peers planning mixed feeding, fathers and mothers planning exclusive breastfeeding described breastfeeding as more natural (p=0.009 and p=0.006, respectively). In addition, fathers who planned exclusive breastfeeding responded more strongly that breastfeeding helped mothers feel closer to their infants (p=0.036) than those who planned mixed feeding. Mothers who planned exclusive breastfeeding indicated significantly more respect for breastfeeding women (p=0.005) and were less likely to describe breastfeeding as harmful to breasts (p=0.024) than those who planned mixed feeding. Table 5 summarizes maternal predictions of paternal views by planned feeding method. Compared with mothers planning mixed feeding, those planning exclusive breastfeeding anticipated their partners/spouses would view breastfeeding as less harmful to breasts (p=0.044) and have greater respect for breastfeeding women (p=0.005).

Discussion

The current study builds on previous research to provide much-needed insight into a poorly characterized population—those who decide prenatally to mix feed their infants. However, the study has some limitations that may have influenced results. First, the sample size was small, increasing the risk of type I errors with multiple comparisons. Second, the population was relatively homogeneous in terms of demographic characteristics; a more diverse group of subjects may have yielded different results. Finally, because subjects could enroll at any time during pregnancy, there was a potential for selection bias during recruitment. For these reasons, the findings from this study should be considered preliminary and not generalized to all expectant parents.

One of the most striking findings in the current study was a deep division in demographic characteristics and attitudes between couples planning mixed feeding and those planning exclusive breastfeeding. From a demographic perspective, mothers planning to mix feed resembled the profile traditionally associated with formula feeding (i.e., younger, lower level of education, and unmarried), whereas those planning to exclusively breastfeed mirrored the profile typically associated with breastfeeding (i.e., older, higher level of education, and married). ³ Furthermore, attitudes that differed significantly between couples planning to mix feed and those planning to exclusively breastfeed—closeness/emotional bonding, support/opinions of others, and naturalness—are themes often cited as playing a role in the decision to formula feed or breastfeed.^13,23–25 Together, these findings lend support to the theory that planned mixed feeding is not a variation of breastfeeding, but rather a variation of formula feeding or a unique method of infant feeding.

In the current study, mothers reported more favorable attitudes toward breastfeeding than fathers over a wide range of breastfeeding issues, encompassing benefits to infant, mother–infant bonding, naturalness, respect for breastfeeding women, interest in additional information, and harmfulness to breasts. Despite differences in instrumentation and attitudinal variables assessed, these results are in general agreement with previous research. Shepherd et al., ²⁶ using a survey that included 14 attitudinal statements related to breastfeeding, reported that breastfeeding mothers had a greater awareness of breastfeeding benefits and were significantly more supportive of breastfeeding than their husbands or partners. In a similar study, Scott et al., ²⁷ using the 17-item Iowa Infant Feeding Attitude Scale, evaluated the predictive value of breastfeeding attitudes in early pregnancy on infant feeding method at hospital discharge: Among couples planning to breastfeed, expectant mothers held more favorable attitudes toward breastfeeding than their husbands/partners. Although the current study did not attempt to explain the discrepancy in attitudes within couples, possible reasons include differences in knowledge of and/or exposure to breastfeeding.^26–29

Although fathers' actual attitudes toward breastfeeding in the current study were less positive than those of mothers, their attitudes were frequently more favorable than predicted. Additionally, there were differences in predictions by planned feeding method: Mothers planning mixed feeding expressed less favorable predictions of fathers' attitudes with respect for breastfeeding women and breastfeeding's harmfulness to breasts compared with mothers planning exclusive breastfeeding. These results are consistent with findings from Freed et al., ³⁰ who noted a general trend of maternal predictions less favorable than actual paternal attitudes and a specific trend of less favorable maternal predictions among mothers planning to formula feed compared with those planning to breastfeed. The parallels between mothers planning formula feeding in the study by Freed et al. ³⁰ and mothers planning mixed feeding in the current study, coupled with the well-documented relationship between paternal support and the decision to breastfeed, suggest perceived negative paternal attitudes may be a factor in a woman's decision to mix feed her infant.^{12,15,30–32}

Breastfeeding promotion and education programs have traditionally targeted mothers; however, there is strong evidence to support the inclusion of fathers in these activities. Wolfberg et al. ³³ examined the impact of incorporating breastfeeding promotion into a 2-hour infant care class for expectant fathers in Maryland: They observed a significant increase in breastfeeding initiation among women whose husbands/partners received the additional breastfeeding information (74%) compared with women whose partners received the standard information (41%). Using a similar design in an intervention trial completed in Italy, Pisacane et al. ³⁴ provided new fathers of breastfed infants with a single 40-minute session on breastfeeding management or general child care: At 6 months, women whose husbands/partners received breastfeeding information reported greater assistance with breastfeeding management (91% vs. 34%), lower incidence of perceived milk insufficiency (9% vs. 27%), lower incidence of breastfeeding cessation due to problems with lactation (4% vs. 18%), and greater prevalence of full (exclusive plus predominant) breastfeeding (25% vs. 15%) compared with women whose husband/partner received general child care information. These findings suggest breastfeeding promotion/education activities provide a very flexible strategy, in terms of timing, content, resources, and population, to increase breastfeeding initiation and exclusive breastfeeding at 6 months, two objectives within Healthy People 2020. ³⁵

Application

Overall, expectant parents in the current study held very positive views about breastfeeding. Yet, the broad range of responses to two of the statements—“Breastfeeding is painful” and “Breastfeeding is acceptable in public”—and the high level of interest in additional information about breastfeeding by both mothers (85%) and fathers (56%) suggest an opportunity for education. The observed discrepancies between mothers' and fathers' views and between mothers' predictions and fathers' actual views imply limited communication on the topic of breastfeeding. Although previous research indicates that paternal breastfeeding promotion and education does not require the presence of the mother to improve breastfeeding outcomes, approaches that foster frank discussion between partners may unify and strengthen couples' attitudes toward breastfeeding. Finally, as the lines between breastfeeding and formula feeding blur, there is a continued need to further characterize factors that influence the prenatal decision to mix feed and to develop strategies that promote exclusive breastfeeding in this population.