An Exploration of the Experiences of Mothers Who Breastfeed Long-Term: What Are the Issues and Why Does It Matter?

Abstract

Background:

The World Health Organization (WHO) promotes breastfeeding for 2 years and beyond. Despite this, only 25% of women in the United Kingdom are breastfeeding at all by 6 months postpartum, with a minority of women breastfeeding beyond the first year. Those who do often report feeling ridiculed or alienated in their choice. Here, the aim was to examine the experiences of women who chose to breastfeed longer term and to seek insight into the ways they felt breastfeeding could be normalized past infancy.

Subjects and Methods:

The study combined two qualitative datasets that explored maternal attitudes and experiences toward longer-term breastfeeding. In Study 1 a combination of methods was used, including interviews, to explore the challenges, attitudes, and experiences faced by women who had breastfed for over 6 months postpartum. In Study 2, 1,319 mothers who were pregnant or had an infant 0–2 years old completed an open-ended questionnaire exploring their attitudes toward longer-term breastfeeding.

Results:

Mothers who had experience of longer-term breastfeeding described how they faced negative attitudes and criticism from others, including the perceptions that longer-term breastfeeding was comical, bizarre, and pointless. Mothers discussed ways in which longer-term breastfeeding could be normalized rather than promoted, targeting health professionals and society instead of encouraging mothers themselves. Key ideas included greater visual representation, increasing knowledge and removing stigma.

Conclusions:

Longer-term breastfeeding needs to be normalized to increase acceptance and in turn reduce the negative attitudes that mothers often face despite following WHO guidance. Greater support is needed from health professionals and in health policy.

Introduction

Breastfeeding is widely acknowledged to be beneficial for both maternal and infant health.^1,2 Consequently, the World Health Organization (WHO) recommends that babies are exclusively breastfed for 6 months postpartum and that following this they continue to receive their mother's milk for “up to 2 years or beyond” alongside complementary foods.³ These international targets are broadly supported at a national level in many countries through government policy and public health promotion activities. The United Kingdom Department of Health, for example, echoes this guidance, although talking less precisely about duration of breastfeeding and how it “can be continued” alongside solid food.⁴

However, in the United Kingdom, although breastfeeding initiation rates are good, many mothers stop breastfeeding within the first few days and weeks, with only 25% of mothers still breastfeeding at 6 months and less than 1% exclusively.⁵ The incidence of long-term breastfeeding in the United Kingdom is estimated to be fairly low, although official measurement can be difficult as even the United Kingdom quinquennial Infant Feeding Survey only records breastfeeding up to 9 months postpartum. Figures collected in 2005 showed that only 18% of women were breastfeeding at all at this time.⁵ With numbers of mothers who artificially feed from birth or who are exclusively artificially feeding by 6 weeks postpartum far outweighing this small percentage, longer-term breastfeeding is thus not a common, normal, or expected behavior in the United Kingdom. Indeed, the United Kingdom has been described as a “formula feeding culture,” with the biological norm of long-term breastfeeding at odds with the social and cultural norm.⁶ Breastfeeding is often associated with very young infants and considered unnecessary for older babies and children. Women who breastfeed “long term” therefore find themselves in a difficult position as they follow public health guidance while at the same time engaging in behavior generally considered by others to be bizarre, even unhealthy.^7,8

The consequence of this is that breastfeeding promotion, literature, and practical support often focus on increasing initiation rates and supporting mothers during the first few weeks postpartum.⁹ The evidence examining the health and other benefits of breastfeeding is substantial, but the vast majority only focuses on breastfeeding in the early days and weeks.^10–12 Although health policy clearly supports longer-term breastfeeding and it has been suggested that the “natural” age of ceasing breastfeeding ranges from 2½ to 7 years,¹³ research examining not only the health benefits of continued feeding but also the wider psychosocial benefits and experiences for mother and infant is not as widely conducted. A handful of studies do explore the positive effects of longer-term breastfeeding upon both infant and maternal health (see, for example, Gulick¹⁴ and Lee et al.¹⁵), although much of this evidence (often cited in support of long-term breastfeeding) is now considerably dated.^16,17 In countries where breastfeeding continuation rates are low (as in the United Kingdom), undertaking further quantitative work on longer-term breastfeeding is problematic as the available sample sizes are very small.¹⁸

However, the issue of longer-term breastfeeding is becoming more publicized. A recent cover of Time Magazine portraying longer-term breastfeeding led to rapid worldwide discussion of the approach.¹⁹ What the debate clearly highlighted was the misconceptions, criticisms, and lack of understanding attached to longer-term breastfeeding held by the media, public, and health professionals alongside “confessions” from many mothers choosing to feed their older infants this way.^20–22 The aim of this article was thus to explore these attitudes and experiences in an empirical form, alongside practically examining what would make women who choose to breastfeed longer term feel more supported and accepted in their choice. Within this it explores the role of health practitioners and contributes to the wider debate of how to increase the acceptance, normality, and incidence of breastfeeding as a whole in the United Kingdom.

Subjects and Methods

This article brings together the findings of two separate but complementary studies exploring women's experiences and perceptions of longer-term breastfeeding. As the aims of both studies were so similar, the decision was made to combine and consider the factors in one empirical article to add greater depth, participant numbers, and perspectives. Study 1 (Dowling) used a combination of ethnographic methods (face-to-face and online interviews with small numbers of women and participant observation in breastfeeding support groups), whereas Study 2 (Brown) used an open-ended questionnaire with a larger group of breastfeeding women.

Participants

Ethical approval was granted for each study through the relevant University Research Ethics Committees. All applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during the conduct of each research project.

In Study 1, 10 women who had breastfed for over 6 months postpartum were interviewed either face-to-face (n=6) or by using online asynchronous interviews using e-mail (n=4).²³ In addition, contact was made with over 80 breastfeeding women via participant observation in breastfeeding support groups. Because of low numbers of women choosing to breastfeed past 6 months postpartum, purposive and snowball sampling was used to recruit participants. Data collection took place over a period of 18 months during the 2008–2010 period. The work was informed by feminist beliefs in the conduct and interpretation of research and was carried out from an “insider” perspective,²⁴ as the researcher was also breastfeeding throughout project design, data collection, and analysis.²⁵

In Study 2 1,319 participants completed an open-ended questionnaire exploring their experiences of breastfeeding and formula feeding and attitudes toward breastfeeding promotion. Participants were either currently pregnant or had given birth in the last 2 years and were initially recruited from local mother and baby groups and through online parenting forums based in the United Kingdom. It was not a requirement for participants to have experience of longer-term breastfeeding, although a proportion of the sample did. Snowball sampling through word of mouth led to the questionnaire being distributed by mother and baby groups across the United Kingdom and through further online advertisements in the form of online blogs, Facebook, and Twitter. Data collection took place over a 3-month period during 2011.

Measures

In both studies interview questions explored how the participants' breastfeeding was perceived both by themselves (before and after they had breastfed) and how they felt others perceived breastfeeding (once they were breastfeeding long term).

Study 1 was also concerned with how women experienced living as long-term breastfeeders and in the sources of support that enabled them to continue breastfeeding when most other women had stopped. Interviews were open-ended and unstructured, although a topic guide was used to focus discussion. Participant observation concentrated on what it was like to be in environments supportive of breastfeeding as well as how breastfeeding longer term was discussed among participants.

Study 2 used an open-ended online questionnaire to examine attitudes toward breastfeeding promotion. Within this, three specific questions targeted beliefs and experiences of longer-term breastfeeding and promotion: (1) “If you breastfed past 6 months what were your experiences of doing so?” (2) “Did you receive any information or promotion of breastfeeding past the age of 6 months? What?” (3) “Should breastfeeding promotion target breastfeeding older babies and toddlers? How?” Participants were encouraged to describe their experiences rather than giving closed responses and indeed did so, giving detailed qualitative responses.

Data analysis

The two datasets were considered separately, but similar data analysis procedures were carried out for both. All data were anonymized and imported into NVivo for thematic analysis. A simple thematic approach was used to generate qualitative description^26,27; each script was read through to identify emerging themes, which were then grouped into key themes and subcategories. In Study 2 these were confirmed by two independent coders with agreement found in over 90% of cases. In Study 1 all coding was undertaken by the researcher and discussed during doctoral supervision.

Data saturation principles were followed during the interviews with data collection continuing until it was felt that no new themes or ideas were emerging. In Study 2 the sample size exceeded recommended minimums.^28,29 Quantitative data collection was allowed to run for a set period of time with numbers far exceeding expectations with data saturation clearly found.

Results

In Study 1, in total 10 women were interviewed; at the time of the interviews they had breastfed for between 4 months (although had experience of breastfeeding for longer) and 6½ years. Inclusion was predicated on having all having breastfed for at least 6 months, within the previous 5 years. Women interviewed online had higher educational qualifications and were more likely to be working outside the home than women interviewed face-to-face. In addition, contact was made with over 80 women in three breastfeeding support groups; these women ranged in age from their early 20s to mid-40s and were breastfeeding babies and children from newborns to 4 years old. Participant observation allowed for increased understanding of the support gained by breastfeeding women as well as contact with women from a greater range of social and economic circumstances. In addition, the use of three methods of data collection enabled triangulation between methods, increasing the “trustworthiness” of the final dataset.³⁰

In Study 2, the mean age of the participants was 30.69 (SD 4.52) with a mean education level of 14.01 years (SD 3.60). Of the participants, 394 were currently pregnant (189 with their first infant), and 1,145 parents had an infant 0–2 years old. Mean age of the infant was 39 weeks (SD 37.25). Two hundred twenty participants had both an infant within the age range and were also pregnant. Ranges of breastfeeding and bottle feeding experiences were seen. Of the mothers, 45.2% were breastfeeding at the time of the questionnaire. Of those who had initiated but stopped breastfeeding, mean duration of breastfeeding among the sample was 18.2 weeks, with a range from 1 day to 2 years. Of the sample, 32.4% had an extended breastfeeding duration of over 6 months.

Overall, a variety of themes were produced describing mothers' beliefs of how long-term breastfeeding is portrayed, experiences of doing so, and how supported they felt in their choices. Suggestions for how health professionals could provide wider support and understanding of the issues mothers face when long-term breastfeeding are considered. It is notable that a key premise running throughout the responses and across thematic categories was the idea that the mothers themselves had often thought differently of long-term breastfeeding before they had breastfed an infant themselves. The importance of this change, the recognition of why these reactions had occurred, and how this could be used to influence social and cultural norms is discussed.

What are mothers' experiences of long-term breastfeeding?

1. Breastfeeding is synonymous with young babies.

A central theme found throughout the responses was the idea that breastfeeding is perceived to be for younger infants only. Mothers themselves noted that before they had given birth they had only visualized themselves breastfeeding a tiny infant, with little thought to how long they might continue:

You get it in your head it's going to be a little baby.

Before my first child I would never have thought I would have fed him until he was nearly four.

Related to this, many mothers commented that the recommendation to breastfeed exclusively for 6 months has become generally interpreted as “breastfeed for 6 months and then stop.” Breastfeeding is perceived as something that happens up to 6 months of age followed by the promotion of “follow-on milks” and the switch from breastmilk to formula milk in the latter part of the first year. Many women see this as normal or inevitable, which is problematic in terms of normalizing the continuation of breastfeeding:

I just assumed that there must be a time that everyone stops, that, you know, you…that's it and then that's that…but I never knew what that age was, I suppose either six months or twelve months, I didn't really know.

My NCT [National Childbirth Trust] teacher asked us how long we were supposed to breastfeed for…cue lots of “um 6 months”…her answer: As long as you can.

Although once mothers were practicing longer-term breastfeeding it became normal behavior to them, many recounted how they had themselves had negative reactions to witnessing older infants' breastfeeding in the past. Mothers talked about being shocked or surprised when they first saw an older baby or child breastfeeding. Most recognized that this was because it was something unfamiliar, outside their experience, and not a course of action that they had considered for themselves:

I was like—”look how big that child is!” it just seems weird, having this child that's walking around and just like comes on over, it's like ohhhhhh. You know, kind of just takes up your whole lap and demands some milk. Weird…and then, and maybe shocking because…I never thought about feeding them that…you know, it just never even occurred to me.

2. Longer-term breastfeeding is “pointless.”

Mothers also described how those around them made the implicit assumption that once their baby had grown older they would no longer be breastfeeding despite the WHO recommendations to consider doing so until 2 years and beyond. The comments made to women about the length of time they breastfeed for indicate that in many people's minds there is clearly a cutoff beyond which it is no longer acceptable (or even comprehensible) to “still” be breastfeeding:

About a year, when everyone else was doing something else and it was “Are you still feeding him? Are you still feeding him?” Now he's eighteen months they just assume that I've stopped, nobody's mentioned it for a while.

Within this it was common for the suggestion to be made that mothers were only continuing to breastfeed at this stage for their own needs or enjoyment:

That was the hardest thing…going to stay with the in-laws and them thinking extended breastfeeding's very strange…they would say, you know, it's bizarre, it's completely unnatural, it's for you not him.

At the most extreme some mothers were informed that by continuing to breastfeed they would harm their child:

The psychologist actually told me that if I continue breastfeeding Janie to help her calm down that I am contributing to her developing an addiction later in life, to anything that she can take into her mouth—food, alcohol, cigarettes, or drugs!!!!

This reaction extended to health professionals. The majority of mothers reported that they had little support or guidance on longer-term breastfeeding, often being met by negative or crude attitudes:

I got no information at all from health professionals…the reassurance and education I got was from a breastfeeding older babies and beyond group on the Babycentre community website.

I had a really bad earache…and I'd gone back and forth to the doctor…she was prescribing something and I said “Can I take that when I'm breastfeeding?” and she said “How long ago did you have your baby?” and he was about eighteen months old, and I'm like “ages ago!”…And they expect him to be really little…So you do kind of think, what are people thinking, you know?

3. Longer-term breastfeeding is bizarre or comical.

Mothers also described how they were often met with the reaction that what they were continuing to do was strange or abnormal behaviour. Others seemed confused as to why they would continue, labeling the mother as unnatural or deviant:

People express surprise if you are breastfeeding longer than a year, like you are a funny person.

It's so important and it's so exciting and it's so easy and yet there's such misunderstanding around it…it's cloaked in all these bad connotations and words.

Occasionally mothers also experienced ridicule or found themselves at the center of jokes around their decision to breastfeed longer term. Breastfeeding a toddler was viewed as humorous but accompanied by disgust and unease:

My Health Visitor actually made crude and offensive jokes about “still” feeding my toddler, even when he was barely a year old.

I got the bitty comment a lot…and “You'll still be feeding when he's at uni” even more.

This woman refers here to the television comedy sketch (“Little Britain”) in which an adult is seen breastfeeding (having “bitty”) in a range of situations. Critically, mothers often felt sad, angry, or simply unsupported by those around them when these views were expressed even in jest:

You're sort of out of synch with the common view aren't you? ’Cos I'm really proud that…I'm still feeding her, I think it's brilliant and it feels like totally the right thing to be doing. But it is sad, it's sad to be in a situation where you don't feel you can be proud of it because people don't understand.

As above, mothers themselves recognized that they too felt that longer-term breastfeeding was surprising or strange when they first encountered it. Emotions described were shock, surprise, and discomfort even though these were women who then went on to breastfeed long term (even though it was not something they had considered when the incidents they described took place):

It was, it was surprising. It's, it's a funny visual…thing, the first time you see it, a, a big boy, with, you know, boots…long legs…I remember being, kind of, impressed, you know, thinking “probably might not do that.”

Mine wasn't so much when I first saw it as when I first heard about it and it was probably my conversation with Marie…she still fed her two and a half year old and I was a bit like, you know, “How are you doing that? Or why are you doing that? And isn't that a bit weird?,” you know, and, and she said “Well it just kind of happened.” And I remember thinking, “this is not going to happen.”

3. Longer-term breastfeeding is a negative experience for the mother.

A final theme raised was the presumption that breastfeeding was in some way a negative experience for the mother. The suggestion was commonly made that the mother had now done enough for her infant and should stop persevering. Alternatively, mothers received comments suggesting that they were being masochistic or martyr-like in their determination:

“Oh well, you've done it for so long now you don't have to put yourself through it any more” and “You've punished yourself enough by breastfeeding her” and “If you don't give up now she's still going to be breastfeeding when she goes to school” and at the moment I've just been sort of smiling and nodding and not getting into it but then it's a problem, isn't it?

One told me I've “gone beyond the call of duty” haven't I?

Overall, mothers faced many challenges predominantly related to the attitudes and behaviors of those around them when choosing to breastfed longer term. However, mothers were adamant that longer-term breastfeeding was beneficial to their infants and should be encouraged. This leads naturally to the findings of Study 2, which consider how the issues of longer-term breastfeeding can be overcome through challenging how breastfeeding is portrayed and promoted within the National Helath Service (NHS).

Does longer-term breastfeeding need to be promoted?

In Study 2, participants were specifically asked whether they felt that longer-term breastfeeding should be promoted and encouraged by health professionals and the NHS. Predominantly the response was positive; breastfeeding should not only be promoted in the early weeks and months but to be continued as long as the infant wishes to continue:

Yes! People should be made aware of the benefits of breastfeeding past weaning and into toddlerhood (and the WHO recommendation that mothers breastfeed for two years and beyond). They should be told that this is normal, not weird, and that babies will still need lots of breast-milk once they start solids.

Although very few responses in the survey were against the concept of longer-term breastfeeding and believed that it should be encouraged and seen as the norm, approximately 25% of the sample did not believe that promotion or support for a longer duration was needed. This included respondents who had themselves breastfed for a longer period of time. Within this, some mothers, however, felt that resources and effort could be better targeted encouraging more women to initiate and continue breastfeeding in the early days:

I think it's all about a good start and support at the beginning. If it doesn't work properly in the first few months people won't continue to breastfeed.

I feel that government and health agencies have enough of a job in persuading and encouraging mothers of small babies to breastfeed and should perhaps concentrate their efforts on this.

Related to this was the concept that promotion at this stage was unnecessary. It was felt that once breastfeeding was established, mothers who find it relatively simple to continue and that many mothers who wanted to breastfeed until this stage were determined and confident enough to overcome the criticism that they face:

I think targeting newborns is most effective as if the mother manages this she will probably naturally be more inclined to keep feeding when breastfeeding is established.

Several participants also made the important distinction that perhaps longer-term breastfeeding promotion needed to target the general public rather than the mothers themselves. They felt that mothers were generally motivated and able to continue breastfeeding if they wished, but the greatest barrier they faced was the attitudes and behaviors of those around them. By equipping their family, peers, and society as to how normal breastfeeding was, mothers would find it easier to continue:

Perhaps with regard to educating the general public but I don't think I would find it that useful as a mother…what info would I need?

Related to this, others suggested that promotion should target NHS professionals rather than the mothers themselves. Many mothers recalled how they received little information or guidance from health professionals with regard to breastfeeding once their infant was more than a few weeks old. Many faced attitudes that breastfeeding was simply not needed or found that professionals expected them to have stopped. It was common for participants simply not to be asked whether they were breastfeeding at any appointment:

Train NHS staff to encourage feeding older children rather than the surprise/shock/negativity you currently get if you are feeding “still” after 4 months.

However, overall there was a strong feeling among both groups of participants that more needed to be done to highlight the importance of longer-term breastfeeding, encourage mothers to continue, and support them in doing so.

How could long-term breastfeeding be normalized?

The results from both studies showed that mothers experienced criticism, barriers, and ridicule when continuing to breastfeed past a few months. The overwhelming attitude was that longer-term breastfeeding needed to be viewed as something “normal” and acceptable rather than an unusual behavior. Within their accounts of their experiences of longer-term breastfeeding, mothers suggested several ways in which longer-term breastfeeding could be normalized and promoted in a healthy fashion. Suggestions including greater visual representation, increasing knowledge, and removing stigma from the context of longer-term breastfeeding, although credence was given to the importance of a gradual change in attitudes to enable society to adapt.

The most central concept was that longer-term breastfeeding had to be promoted as a stronger social and cultural norm rather than abnormal behavior. People had to start accepting that longer-term breastfeeding was not only the biological norm but an acceptable and common behavior, seen as important in many cultures:

I think it should normalise it more; just having a tiny newborn makes people think only tiny babies should be breastfed.

People need to realise that breastfeeding a child of any age is perfectly normal.

Within this mothers felt that more needed to be done to increase knowledge as to why longer-term breastfeeding is important for infants. Emphasis had to be placed on the knowledge that longer-term breastfeeding had health benefits over and above follow-on milk or cow's milk, that milk was still an important element of an infant's diet, and that breastfeeding offered many more additional benefits to the older infant:

People should realise that babies are not biologically designed to be weaned from the breast at six months, a year or even two years.

Promotion could explore issues and myths around teeth, speech, biology, continued benefits physically and emotionally, feeding whilst pregnant and tandem feeding.

Alongside this, challenging the misconceptions and taboos that are held in society regarding the concept of longer-term breastfeeding was felt to be critical:

People are so bizarrely uncomfortable about children nursing after the age of a year or so. It seems really unhealthy the way many people are uncomfortable with it.

A key element to this was supporting longer-term breastfeeding to become more visually represented in public, so that seeing an older infant breastfeeding in public would be considered more socially acceptable rather than something “shocking.” One popular suggestion was the idea that NHS and Government material promoting breastfeeding should include pictures of older children breastfeeding:

Posters, TV adverts, hand outs from professionals.

Promotional materials should have a section indicating that it is ok to breastfeed for as long as possible with…pictures of older babies feeding rather than younger

Related to this was the concept of moving away from the language used in promotion that highlighted the 6-month time frame. More emphasis should be placed on breastfeeding for a year or longer with the idea that solid foods should be introduced alongside milk at around 6 months old:

…stop the promotion of “up to 6 months” which leads people to think that this is a maximum target.

I know lots of people who happily breastfed for 6 months then felt they had done their bit and started formula feeding…there should be more information on the continued benefits.

One suggestion on how this could work by removing the idea of a time frame was the concept that breastfeeding could continue for as long as the infant wishes to or the mother is happy to:

The message needs to be breastfeed as long as you both want to, and add food at around 6 months …

However, the importance of timing of introduction of materials both to the mother and to society itself was raised. It was recognized that perhaps exposure needed to be gradual and integrated into promotional materials and publications a step at a time. The data clearly show that even these mothers who themselves were long-term breastfeeding had felt shocked or surprised before their experiences when encountering older infants breastfeeding. On the one hand, images of breastfed children needed to become more commonplace, but this needed to be done in a sensitive way to ensure that a shock factor was not created.

…I think if you promote toddler feeding to a pregnant or new mum too much it can be a bit terrifying as toddlers look huge and rather strange. Perhaps more information should be given in stages and gently filter in the idea of breastfeeding an older child?…

Participants felt that perhaps although society gradually needed to become adjusted to the idea of, and view, longer-term breastfeeding, perhaps new parents needed the information one step at a time. Initially information needed to target establishing breastfeeding, but over time literature could emphasize continued breastfeeding. On this note, one challenge to promotion was the idea that encouraging mothers to continue breastfeeding for a longer period may lead to more mothers feeling under pressure if they cannot continue when they return to work or their infant decides to no longer feed. Mothers felt that emphasis needed to be placed on how well mothers had done to breastfeed at all, but continued breastfeeding was beneficial:

I do think there needs to be a fine line—the idea of feeding a nearly three year old was terrifying when I had a new baby but it's something that has developed with our relationship.

Start off with smaller chunks…things like “if you breastfeed for two weeks.…if you breastfeed for one month…” and then build up.

Overall, the key message that emerged from the data was that steps needed to be taken to normalize longer-term breastfeeding. In general, mothers did not feel the approach needed to be promoted and publicized, but more that a gradual remodeling and conceptualization of longer-term breastfeeding was needed to enable more mothers to feel accepted and comfortable in following public health guidance.

Discussion

This article presented the findings from two studies exploring the portrayal and experience of longer-term breastfeeding. Key themes focused around the central standpoint that longer-term breastfeeding, although the biological norm, was not considered a social norm. Indeed, longer-term breastfeeding was viewed as something abnormal, strange, or harmful or indeed excluded from public portrayal at all through the absence of literature pertaining to discussion and photographs of older infants breastfeeding. This echoed previous work in the area where women felt in the minority, isolated in their choices, and as if they were doing something abnormal.^31–33

The question arises as to how the perception of longer-term breastfeeding can be normalized. One theme that arose from the data was that mothers felt that longer-term breastfeeding did not necessarily need to be directly encouraged and promoted by health professionals (with effort perhaps being focused on the earlier stages, with the expectation that if breastfeeding got off to a good start, more mothers would naturally continue). However, mothers, especially those who had experience of longer-term breastfeeding, strongly wished for it to be seen as more natural, normal, and acceptable and for society and others to feel comfortable with the concept. This brings the discussion back to how mothers believed this state could be gradually reached, targeting not only parents but health professionals and wider society too.

One criticism was that breastfeeding literature rarely extends to portraying an image of a young infant, presenting the assumption that breastfeeding is only for newborns. One suggestion could thus be that pictures are presented in NHS leaflets promoting breastfeeding or indeed general parenting such as the Birth to Five publication in the United Kingdom, which covers all aspects of infancy and preschool parenting.³⁴ Caution, however, perhaps needs to be given to inclusion of such pictures in newborn sections due to the potential “shock” factor experienced even by mothers in the early stages of seeing an older child breastfeeding who themselves went on to long-term breastfeed. Inclusion could naturally occur when discussing issues with older babies and toddlers.

The second and related issue could involve greater training and education in the benefits of breastfeeding older infants and children for health professionals working with mothers. A common finding was that mothers who longer-term breastfed often encountered negative attitudes or simply a lack of awareness or understanding from doctors and health visitors, despite having WHO recommendations on their side.

Finally, the normalization of longer-term breastfeeding needs to be targeted at a society-wide level. This is a difficult conundrum to manage, as mothers of younger infants often report disdainful attitudes and ignorance from family members, peers, and the general public when breastfeeding.³⁵ Again, perhaps a gradual integration is needed, using techniques to both educate and raise publicity of the benefits of longer-term breastfeeding over time. Alongside a wider acceptance among health professionals, greater inclusion of images of older infants breastfeeding in books, television programs, and advertising was suggested. Essentially, women wanted longer-term breastfeeding to be more common encountered and seen by a wider section of the public so that over time it became another normal event to see.

Overall, the findings portrayed a clear message that mothers needed more support in their decision to continue breastfeeding past the early weeks and months. However, further work is needed to explore the benefits of longer-term breastfeeding, not only for infant and maternal health but exploring psychosocial impact, child development, and relationships. Although criticism is made of the lack of research based in the developed world as to the health benefits of continued breastfeeding, the nutrient content of breastmilk during the second year suggests it is certainly a nutritious food choice.³⁶ Conversely, despite denigration of the approach by some as harmful to the infant's psychological development, there is no evidence to support this. It is possible that further research would be a driving factor in promoting greater awareness and support for mothers choosing to breastfeed longer term. If further evidence suggests more concrete health benefits to the approach, more women may choose to breastfeed for longer, potentially enabled by heightened support. In turn this would stimulate further research, continuing the cycle and building the evidence base. However, despite this criticism, this article begins to highlight the needs and ideas of women who are choosing to breastfeed long term in the United Kingdom, reinforcing the call for further support and education.

In conclusion, mothers wanted to feel that their decision to follow a biologically normal act, which is supported by public health policy, could also be accepted as normal by their family, health professionals, and society as a whole. Making longer-term breastfeeding more visible, re-educating those around the mother, and removing the stigma and taboo surrounding feeding an older infant were considered important steps along this journey.

Footnotes

Acknowledgments

S.D.'s PhD research (on which elements of this article are based) was supported by a studentship from the Faculty of Health and Life Sciences, University of the West of England, Bristol, 2007–2010.

Disclosure Statement

No competing financial interests exist.

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