The Factors Influencing Young Mothers' Infant Feeding Decisions: The Views of Healthcare Professionals and Voluntary Workers on the Role of the Baby's Maternal Grandmother *

Abstract

Background:

Increasing rates of exclusive breastfeeding for the first 6 months of life is important to ensure that infants achieve “optimal growth, development, and health” and could generate over £40 million in annual savings for the National Health Service. Interventions targeting young mothers are recommended because of low breastfeeding rates. Women's mothers have been identified as potential influences on whether women choose to breastfeed. This study explored health, social, and voluntary care professionals' perceptions of young mothers' attitudes to breastfeeding and the role of maternal grandmothers.

Materials and Methods:

Semistructured interviews were conducted with nine professionals working with young mothers. Thematic analysis was used to interpret data and identify key themes.

Results:

Professionals felt that prevalent attitudes among young mothers who bottle fed were that breastfeeding is embarrassing, deviant from the social norm, and detrimental to their social life and relationships but that women understand the health benefits. Grandmothers were identified as important influences on some women, and, in particular, concerns were raised that grandmothers sometimes undermined intentions to breastfeed by offering to bottle feed infants. However, potential problems with involving grandmothers in breastfeeding promotion strategies were identified, and more pressing issues were raised, particularly inadequate postnatal support for young mothers.

Conclusions:

Professionals recognize grandmothers as an important influence and source of support for many mothers but identified other priorities for interventions, particularly improving the level of support in postnatal care. Their ultimate focus is to build positive relationships with women and empower them to make informed decisions.

Introduction

Substantial evidence suggests that exclusive breastfeeding for the first 6 months of life is the best way to ensure that infants achieve “optimal growth, development, and health.”¹ Therefore, at the population level, a “modest increase” in rates could produce an annual saving of over £40 million for the National Health Service.² Although overall rates of breastfeeding are increasing in the United Kingdom, variation between demographic groups still exists. In 2010 only 58% of mothers under 20 years old initially breastfed compared with 81% of all mothers.³ Being white, less educated, and from a lower socioeconomic background were also factors associated with low breastfeeding rates.⁴

Research suggests that an infant's maternal grandmother can affect mothers' feeding decisions and breastfeeding duration.^5–9 In particular, they can be a vital source of “practical support, empathy, and approval.”¹⁰ In 2004 the Department of Health identified the importance of engaging such “individuals of influence” when trying to reach groups who are difficult to target such as adolescents.¹¹ Similarly, a study in Sweden proposed “a helpful support strategy for health professionals might be to mobilize grandmothers with positive breastfeeding perception to provide support for their daughters' breastfeeding.”¹² A study investigating the impact of an educational session for grandmothers found significantly higher rates of breastfeeding at 8 weeks than in the surrounding area.⁷ However, there is little research investigating professionals' perceptions of factors affecting young mothers' infant feeding decisions and how this impacts on their willingness to engage with grandmothers. Therefore, this study explored health, social, and voluntary care professionals' views on young mothers' attitudes to breastfeeding and the role of maternal grandmothers. The objectives were:

1. To explore their perceptions of young mothers' attitudes to breastfeeding

2. To investigate their experience of the role of maternal grandmothers in influencing infant feeding decisions

3. To determine whether professionals would value strategies aiming to mobilize the support of maternal grandmothers and would be willing to engage with them

Materials and Methods

Ethical approval was granted by the University of Leeds, the Leeds Community Healthcare NHS Trust, and the Leeds Teaching Hospital NHS Trust. Permission was also obtained from the Early Start Workforce Development Group at Leeds City Council.

A qualitative approach was used involving semistructured interviews based on a topic guide consisting of broad, relevant questions. This helped to obtain a deep understanding of professionals' perceptions.¹³ Interviews were conducted at participants' place of work between April and May 2013. Interviews lasted approximately 45 minutes until participants confirmed they had nothing further to add. Purposive sampling was used to select organizations whose staff would have the most relevant experiences discussing infant feeding with mothers under 20 years of age. The final sample comprised a family nurse, two specialist teenage midwives, two health visitors, two voluntary group staff, and two Children's Centre staff.

Thematic analysis based on aspects of Colaizzi's seven-step method was used.¹⁴ This approach was adopted as its clearly structured, linear format facilitates a systematic and detailed analysis of data.¹⁵ First, transcripts were read several times to gain an overall understanding of the issues raised. Significant statements relating to the study's aims and objectives were identified. These were copied to a separate document and labeled according to participant. The meaning of each statement was then considered, and statements were grouped into categories according to their semantic content.¹⁴ These were used as codes to label the transcripts, and discrepancies were considered, to permit any necessary revisions of themes.¹⁶ An exhaustive description was developed from the themes when considering the study's conclusions. Participants did not validate findings as proposed by Colaizzi to avoid placing additional demands on participants.¹⁴ Instead, validity was increased by the use of a second coder who labeled one page of transcript with the list of themes and found a high degree of congruence demonstrating that the categories were explicable, distinct, and representative.

Results

Embarrassment

Participants felt embarrassment was a major issue that stemmed from the fact that women's youth meant they had not “learnt about [their] own personal space within [their] body, never mind within [their] home, never mind within the outside factors.” Some participants felt women were often unfamiliar with their anatomy and lacked “confidence in their relationship with their body.” Therefore, mothers could not reconcile the idea of breasts as a source of infant nourishment into their existing self-concept and were unable to overcome the self-consciousness generated by the perception of their breasts as sexual. Participants felt that feeding in the house was problematic for women still living in the parental home as they lacked the “privacy to find somewhere to go and practice how to breastfeed.” Similarly, feeding in public was described as both a “massive issue” and a “real barrier” due to anxiety about revealing breasts or receiving negative comments from others.

Social norms/approval

Participants all felt that the majority of young mothers that they worked with regarded bottle feeding as “normal” to the extent that for some the element of choice was removed. One said, “It's not a decision you know I will bottle feed, it really isn't that conscious, it is you know I'll feed my baby and when you have the idea of how you feed your baby, your baby's got a bottle.” Mothers' perceptions were felt to stem from their experiences of seeing infant feeding, in their family, community, or the media, and believed to be ingrained from a young age. In particular, participants felt the grandmother's own feeding behaviors played a significant role in determining what the women considered normal, with many participants raising the idea that “we follow our family's footsteps.” Consequently it was felt that women needed a lot of confidence to go against the cultural norms or the family's wishes. A participant felt “for the young women who breastfeed their children they're doing something that's really, really out of the ordinary, total step away from the norm from within their community and that's a really difficult thing to ask somebody who is 15, 16, 17 to do.”

Conversely, participants said that women tended to view breastfeeding as the domain of the middle-class mother: “It's just perceived and painted and marketed in such a middle-class way…It's like Jamie Oliver and Heston Blumenthal talking about healthy food, that's not going to filter down, you want Ant and Dec or Jordan on ITV.” This illustrates that participants felt mothers were unable to identify with positive breastfeeding role models.

Effect on lifestyle

The majority of participants believed mothers saw breastfeeding as a “commitment” because they would be solely responsible for feeding the baby. The increased frequency of feeds was also seen as inconvenient. Participants felt women saw bottle feeding as less restrictive because their families could help with feeds. Desire for support for night feeds was considered particularly influential, with one participant stating “I think they're always thinking right if it's got a bottle it can go elsewhere.”

Role of partners

Three participants did not consider partners to be influential among the women with whom they worked because the majority were single parents. Others reported some fathers who wanted the healthiest food for their babies and others who felt breastfeeding conflicted with their view of breasts as sexual or desire to feed their babies themself. Most participants felt that for mothers in relationships, partners were a large influence, but often because of women's concerns about how breastfeeding would affect the relationship rather than direct opposition from the partner. One believed, “they feel how would it affect their relationship with the partner or how the partner might feel if their breasts are now not for the partner, they're for the baby.”

Health

Generally professionals believed that women understood the health benefits of breastfeeding but that this knowledge did not correlate with their own experiences of seeing healthy bottle-fed babies. One participant said, “When you're talking about the benefits to the baby, all they can see is hundreds of families around them bottle feeding their babies with what look like fit healthy children, even themselves included perhaps in that.” Similarly, one participant felt that their lack of experience of ill children made the idea of their child's health abstract. Furthermore, it was felt that often mothers' awareness of health benefits was outweighed by other more influential factors, with one participant saying “They know the positive aspects, but the negatives seem to in their minds outweigh the positives; it's a strange battle.”

Benefits of involving grandmothers

Grandmothers were identified as an existing source of support for women so they were regarded as approachable figures. One participant stated, “I don't think they'd like to ring a stranger to say 'I'm not managing to breastfeed' so it would probably be, you know, that they say to mum, I'm so tired.” However, only one participant generated ideas about how to engage with grandmothers in order to generate positive attitudes towards breastfeeding, raising the view that “it's about involving them when we do one-to-one, you know, sessions and antenatal checks, encouraging them to be present.”

Barriers to involving grandmothers

Participants raised the issue that grandmothers would be hard to target in interventions, describing them as “really difficult to engage.” Additionally, the belief was raised that grandmothers' attitudes would be as difficult to change, if not more so, than their daughters' attitudes. In particular, an additional motivation of grandmothers was raised, that they had an innate desire to adopt aspects of the motherly role, especially the ability to help feed the baby. One participant articulated the belief that “parents kind of step in and take over the parenting role so they want to do the feeding.” It was also felt that schemes would be unsuccessful in cases where women did not have close relationships with their mothers. Additionally, the potentially detrimental effect on a mother's relationship with her daughter if she promoted breastfeeding too forcefully was considered.

Empowerment

All participants except one discussed not wanting mothers to feel pressured to breastfeed and instead aimed to equip them with the information to make an informed decision. One stated that “You should empower women to want to be able to, to want to breastfeed, rather than guilting them into feeling bad when they don't.” This illustrates that the participants felt that forcing the issue too strongly might be detrimental to their relationship with mothers and to her well-being.

More important barriers/strategies

Overall, although grandmothers were perceived to be a major source of information and advice, participants generally raised other concerns they felt were more important to address. The need to return back to school was identified as an issue for mothers still in education. A suggestion made by one participant that providing incentives for women to breastfeed might encourage them to try it and become more comfortable with the idea. Some participants identified the need to alter the whole community's attitudes to help to combat the issues of feeding in public and negative attitudes of partners. In particular, they suggested more education about breastfeeding in schools or greater media portrayal of breastfeeding, feeling that it would be of use for young mothers to have breastfeeding role models they could “relate to a lot.”

Some participants suggested that to help overcome mothers' fear about feeding in public, they should be provided with more information about discreet ways of feeding in public. Additionally, some participants were concerned that mothers struggled to afford specific clothing to facilitate breastfeeding in public, especially as they would only use it for a short time. It was proposed that women would benefit from being given vouchers for this and that having more fashionable breastfeeding clothing would help to capture their interest.

The most predominate concern raised by participants was about inadequate breastfeeding support for young mothers in the hospital and the first few days after birth. One stated, “Some of the practices in the acute hospitals don't facilitate or enable or back up the intention to breastfeed.” Participants raised the issue that midwives had too many demands upon their time and so were unable to devote sufficient time to breastfeeding support, feeling that young mothers were “a little bit forgotten and a little bit neglected on the support side.” Other participants felt that young mothers were uncomfortable asking for help from midwives with whom they had not developed a relationship and were less likely than their older counterparts to be proactive in seeking help. One participant was concerned that because of a general perception that young mothers are unlikely to breastfeed, staff will not focus on offering them support. Another described a case where a baby was bottle fed before her mother was able to explain her intention to breastfeed, illustrating the risk of making such assumptions.

Discussion

In keeping with much of the literature, professionals felt that young mothers who bottle feed predominantly understand the health benefits of breastfeeding but regard it as embarrassing, inconvenient, deviant from the social norm, and potentially detrimental to their relationship. For example, focus groups of 14 pregnant teenagers found they were concerned about feeding in public, pain, and the “complexity” of breastfeeding but were aware of the health benefits.¹⁷ Embarrassment was felt to stem from the dichotomy of the breast as a sexual object and a means of providing infant nourishment. Fueled by young women's lack of confidence in their bodies, this attitude was felt to contribute to mothers' concerns about how breastfeeding would affect their partners' perceptions of them. Similarly, Dyson et al.,¹⁸ who studied focus groups of 17 pregnant teenagers, identified bottle feeding to be the “moral norm” and found that the perceived “sexuality of the breast” generated embarrassment that required high levels of “self-esteem” to overcome.

The finding that the infant's maternal grandmother affected young mothers' feeding decisions through creating perceived norms is in keeping with the study of Giles et al.¹⁹ They found that among 2,021 13–14 year olds, those who were breastfed or had seen breastfeeding were significantly more likely to intend to do so themselves. Attitudes about the health benefits and convenience of breastfeeding were also felt to be shaped by grandmothers. Participants said that women who had been bottle fed themselves reportedly cited their own health as evidence that breastfeeding was not significantly superior. This parallels the finding of Hoddinott and Pill²⁰ that exposure to breastfeeding by a relative or close friend was more influential than “theoretical knowledge” about its benefits. Participants felt that the perception of bottle feeding as more convenient was fueled by grandmothers' offers to bottle feed, with the desire for assistance with night feeds seen as particularly influential. The importance of this was demonstrated by a questionnaire study at Liverpool Women's Hospital in which 52% of 23 teenagers who chose not to breastfeed cited inconvenience as the main reason.²¹

Despite recognizing women's mothers as influential figures, overall, participants felt targeting them in promotion schemes would be problematic. The practical difficulty of engaging grandmothers was raised as an issue. Professionals' experience of the varied quality of women's relationships with their mothers meant they found it hard to predict the impact of such strategies. Additionally, grandmothers were regarded as potentially closed-minded, having similar societal influences to their daughters. This was seen in a study of 26 grandmothers who participated in activity sessions about breastfeeding because although their levels of knowledge increased, their intention to recommend breastfeeding did not change.²² Participants also perceived additional motivations for favoring bottle feeding that might be difficult to modify. Specifically, they believed that some grandmothers wanted to adopt the motherly role because of an instinctual desire to nurture. Similarly, four focus groups in the United States found that mothers believed grandmothers regarded breastfeeding as a barrier to their ability to provide care and bond with the infant.⁸ Likewise, focus groups in a deprived part of the United Kingdom identified mothers' perception that grandmothers felt excluded by breastfeeding.²³

A key finding of the study was the emphasis that professionals placed on “empowering” women to make informed decisions. Participants felt their role was a fine balancing act between being too authoritarian and making insufficient attempts to engage mothers. Therefore, participants sought to increase mothers' knowledge but were respectful of a decision to bottle feed when they regarded it as a rational choice based on consideration of lifestyle, relationships, and cultural values. Consequently, this generated the perception among some participants that mobilizing grandmothers as “individuals of influence” would be “unhealthy.” However, participants were also concerned that societal expectations might create the assumption that encouraging mothers to breastfeed was futile owing to their age when actually insufficient information, support, or encouragement was offered. Therefore, a key finding of the study is that professionals would most value interventions addressing barriers faced by women who already have an intention to breastfeed such as problems with feeding in public and support during early days.

A major issue identified in this study was concern about inadequate levels of postnatal breastfeeding support in the hospital. This is in keeping with the questionnaire study of Hunter²⁴ of mothers under 19 years of age in Oxford, which found that only 57% felt they were given “enough help and advice about feeding their baby.” Only 48% of the 81% of mothers who stated an intention to breastfeed actually initiated it.²⁴ Participants felt that mothers had to be very assertive to get assistance and that young mothers may be unwilling to ask for help, especially from unfamiliar staff. This occurred in a United Kingdom study²⁵ in which teenagers were concerned by a lack of continuity of carer and a Canadian study²⁶ where young women worried their mothering skills would be deemed inadequate. Participants felt midwives were often overworked, in keeping with the views of 20 professionals interviewed in a recent study.²⁷ As previously identified, concern was also raised that hospital staff might neglect young mothers because they assume they will bottle feed, as seen in a study of 138 young mothers in Swansea.²⁸

Hunter²⁴ suggested that an effective strategy to increase initiation may be to provide targeted hospital care. Maternity support workers have been employed by the NHS since 2005 to make “more efficient use of midwifery team skills.”²⁹ A study exploring their use to “facilitate family focused breastfeeding support” found it to be an effective intervention but concluded that because of resources it would be best limited to selected women such as teenagers.³⁰ Therefore, as the most pressing concern raised by professionals, further research into young mothers' experiences of support for breastfeeding during early days and the potential role of a specialist teenage maternity support worker would be of use.

Although this study's findings are not generalizable, triangulation was used to ensure that a wide range of professions' views was represented. Therefore, it has generated a deep understanding of professionals' perceptions of breastfeeding promotion and willingness to engage with grandmothers. Participants chose to take part of their own volition so may be particularly enthusiastic about breastfeeding and its promotion. However, this enabled them to provide a valuable insight into the topic. Conducting interviews at participants' place of work limited the researcher's control over the suitability of recording and degree of privacy but is likely to have increased participants' willingness to engage.

Conclusions

In conclusion, professionals identified attitudes of young mothers that were similar to views reported in much of the literature. Overall, they felt that women understood the health benefits of breastfeeding but regarding it as embarrassing, inconvenient, deviant from the social norm, and potentially detrimental to relationships. While recognizing women's mothers often affect their infant feeding decisions, professionals raised concerns about involving grandmothers in breastfeeding promotion schemes: in particular, the difficulty of trying to engage grandmothers, the view that their opinions would be as fixed if not more so than their daughters' attitudes, and the belief that pressuring mothers to breastfeed is unethical. Professionals felt that instead their role was to empower women to make informed decisions and provide support. Therefore, they were more concerned about barriers hindering women who already had an intention to breastfeed. Due to concerns raised about support in postnatal care, further research into young mothers' experiences of support for breastfeeding in the first few days after birth would be of use. This study has identified that professionals are committed to promoting breastfeeding but that their primary concern remains maintaining good relationships with women and supporting them to raise a “happy and healthy” child.

Footnotes

Acknowledgments

Acknowledgements to Laura Stroud, Leeds City Council, Leeds Community Healthcare NHS Trust, Leeds Teaching Hospitals NHS Trust, study participants, and the University of Leeds Alumni Annual Fund.

Disclosure Statement

No competing financial interests exist.

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