Father's Role in Breastfeeding Promotion: Lessons from a Quasi-Experimental Trial in China

Abstract

Aims:

The aims of this study were to evaluate the effectiveness of an educational intervention involving fathers on breastfeeding initiation and exclusive breastfeeding rate, and to explore mothers' perceptions of their partners' support of breastfeeding.

Materials and Methods:

This study was a quasi-experimental pretest–posttest design with two groups. A convenience sample consisting of 72 expectant mothers was recruited. Thirty-six women with their partners were assigned to the intervention group, and 36 women alone were in the control group. Both groups were offered similar education contents, and the intervention group was given additional information on how fathers could support their partners, both emotionally and physically, during the breastfeeding process. Student's t test, chi-square test, and Mann–Whitney U test were used to detect group differences.

Results:

The prevalence rates of exclusive breastfeeding at 4 months and 6 months of the intervention group were significantly higher than there were in the control group (51.4% and 26.4%, p = 0.034; 40.0% and 17.6%, p = 0.041). Women in the intervention group were less likely to use infant formula at 1 and 6 months postpartum (5.6% and 23.5%, p = 0.032; 20.0% and 44.1%, p = 0.032). Related to the process of breastfeeding, partners in the intervention group supported their partners by taking care of the infant, doing housework, and providing emotional support.

Conclusions:

Involving the fathers in breastfeeding education could improve the exclusive breastfeeding rate and prolong the duration of exclusive breastfeeding. The mothers appreciated support from the fathers.

Introduction

Breastfeeding contributes to the health and well-being of mothers, reduces family and national expense, protects the environment, and is a secure way of feeding.¹ Breastfed babies achieve healthier growth and optimal development compared with those fed by formula.²

One of the 2025 global targets is to increase the rate of exclusive breastfeeding during the first 6 months up to at least 50%.³ In 2011, the China State Council established the same goal to improve exclusive breastfeeding.⁴ However, <40% of infants <6 months of age are exclusively breastfed.⁵ In Mainland China, the rate of early initiation of breastfeeding in 2008–2012 was 41%, and the rate of exclusive breastfeeding for <6 months was 27.6%.⁶ In Hong Kong, the exclusive breastfeeding rate in different postpartum stages was higher than in Mainland China.⁷ Thus, the situation in China is grave, and effective strategies are needed to improve the breastfeeding rate.

Breastfeeding as a human nature is influenced by many factors. Breastfeeding barriers such as difficulties in lactation, poor community acceptability, having to return to work, perceived insufficient milk, lack of breastfeeding knowledge, and lack of confidence have been explored.^8–10 In China, breastfeeding practices have been reported to be affected by the increasing rate of cesarean births.¹¹ Chinese mothers requesting a cesarean delivery are statistically less likely to breastfeed their infants exclusively compared with those who have a vaginal delivery.¹²

In order to identify strategies to promote increased breastfeeding rates and facilitate maternal and infant health, a large number of research studies have been done. One of the positive aspects found to influence breastfeeding is support from partners.^13,14 Fathers' breastfeeding beliefs played a key role in mothers' final decision of a feeding model,^15,16 and fathers' support was associated with the initiation and duration of breastfeeding.^17,18 Mothers also appreciated the support from fathers rather than professional staff.¹⁹ However, fathers did not know how to offer support due to a lack of breastfeeding knowledge.^20,21

Several experimental studies have shown that with the father's involvement in a breastfeeding educational intervention, the exclusive breastfeeding rates at 6 weeks,²² 4 months, and 6 months^23,24 were significantly increased in Western cultures. Wolfberg et al.²⁵ conducted a randomized controlled trial offering a 2-hour simple educational intervention to 59 fathers and found that the breastfeeding initiation rate in the intervention group was significantly higher than that in the control group (74% versus 41%). Susin and Giugliani²³ stated a similar result. Maycock et al.²² concluded that older fathers or fathers with higher socioeconomic status were associated with higher breastfeeding rates at 6 weeks postpartum. However, a survey conducted in China by Lu et al.²⁶ suggested that fathers with higher education levels and higher incomes might lead to a lower breastfeeding rate.

The objectives of this study were to evaluate the effectiveness of an educational intervention involving fathers on the rate of breastfeeding initiation and duration of exclusive breastfeeding, and to explore mothers' perceptions of partners' support for breastfeeding. The research questions were as follows:

RQ1: What is the effect of the father's involvement after an educational intervention on parental knowledge and attitude toward breastfeeding?

RQ2: What is the effect of the father's involvement after an educational intervention on breastfeeding initiation, and what is the exclusive breastfeeding rate at 1, 4, and 6 months postpartum?

RQ3: What are the mothers' perceptions of their partners' support of breastfeeding?

Materials and Methods

Design

This is a quasi-experimental study including two groups. Mothers and their partners in the intervention group participated in the educational intervention, while mothers in the control group participated in the program alone. This design was used to examine whether there was a difference between the two groups. Each group completed a pretest–posttest to measure the effectiveness of the educational intervention.

Setting

This study was conducted at a baby-friendly university hospital in Wuhan, south central China.

Participants

Participants included mothers and their infants' fathers. Inclusion criteria were: (1) mothers and fathers were ≥20 years old; (2) the mothers' gestational weeks were ≥39; (3) the couple (mother and infant's father) lived together; (4) no gestational complications; (5) first-time mothers; (6) singleton fetus; and (7) all participants able to read and understand Mandarin. Exclusion criteria were: (1) the mother experienced serious medical problems or mental illness after delivery; (2) the couple divorced or planned to migrate to another city during the intervention and follow-up periods; (3) no access to a telephone; (4) neonatal death; or (5) infants with neonatal diseases who were separated from their mothers.

A total of 72 eligible participants were recruited in maternity units from July 1, 2014, to October 2, 2014. Participants were divided into different groups by time sequence. A sample size of 72 was calculated based on G POWER v3.1 to provide statistical power ≥80%, 5% level of significance, an effect size of 0.66,²⁶ and assuming a loss of follow-up of 20%.

Instruments

The Iowa Infant Feeding Attitude Scale (IIFAS) and the Breastfeeding Knowledge Scale (BKS) were used to measure the breastfeeding attitude and breastfeeding knowledge level of mother and father pairs in the intervention group and mothers only in the control group. The reliability and validity of the IIFAS has been assessed by studies undertaken in English-speaking populations,^27,28 and it has been translated into Mandarin with good reliability and validity.²⁹ The BKS with a high level of internal reliability was used to measure breastfeeding knowledge.³⁰

Intervention program

Antenatal breastfeeding education was provided for couples in the intervention group and mothers in the control group. The educational materials were selected from the Web sites of the World Health Organization (WHO; www.WHO.org) and La Leche League International (www.llli.org). In the intervention group, a “father support” model was used to foster father involvement in decision making with mothers on a feeding model and in supporting breastfeeding practices through emotional and physical aspects. Sherriff et al.³¹ created this father support model, which aims to clarify the meaning of “father support” and allows health facilitators to comprehend and apply it in practice and research. The educational intervention was tested by three obstetricians, three senior midwives, and three senior nurses working in an obstetrics unit. The design of the content is shown in Table 1.

Table 1.

Intervention Outline

Lecture

1. Basic knowledge of breastfeeding:

1. Benefits for infants

2. Benefits for mothers

3. Risks of non-breastfeeding

2. Breastfeeding techniques:

1. Stomach capacity of the newborn

2. When to start breastfeeding

3. Breastfeeding positions

4. Common problems during breastfeeding and their solutions

3. Additional content for fathers (intervention group):

1. Involvement in decision making on feeding model:

(a) Validation of the mother's feeding decision

(b) Ongoing involvement in decision making regarding feeding

2. Emotional support for breastfeeding:

(a) Being there

(b) Affection and encouragement

3. Practical support for breastfeeding:

(a) Accepting, learning, and implementing the support role

(b) Meeting the needs of mother

Skill training

1. The researcher demonstrates the correct breastfeeding positions

2. Practice

3.The fathers demonstrate how they can help mothers and practice

Discussion and feedback

1. Do you have any misunderstanding about breastfeeding? If so, what is it?

2. What new knowledge did you gain as a result of the class?

3. What issues are you concerned about?

The breastfeeding education program lasted 60–90 minutes, and there were four to eight participants in each class. PowerPoint presentations, breast models, and newborn dolls were used during the class. Each participant was given a booklet about breastfeeding following the education program.

Data collection

Before the intervention, the socio-demographic characteristics of the participants were obtained using a baseline questionnaire that was distributed on the maternity ward. Variables included parental age, income, education level, sex and weight of newborns, and the mode of delivery.

Before and after the intervention, couples in the intervention group and mothers in the control group were asked to complete the IIFAS and the BKS in order to identify any differences between the groups.

After delivery, the mothers were interviewed four times. The first interview was conducted face-to-face upon hospital discharge. At 1, 4, and 6 months postpartum, the interviews were conducted by telephone. An outline of each interviews is given below.

Infant feeding pattern (exclusive breastfeeding versus complementary feeding)

Breastfeeding categories were established according to WHO recommendations.³² Exclusive breastfeeding means that the infant receives only breastmilk, and no other liquids, including water or solids, are given, with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals, or medicines. Complementary feeding means that the infant receives breastmilk and food or liquid including non-human milk and formula milk.

Father's attitude

Mothers were asked what their partners' attitude toward breastfeeding was, and how their partner supports breastfeeding.

Data analysis

SPSS Statistics for Windows v19.0 was used for statistical analysis. The t test, Mann–Whitney U test, and chi-square test were used to detect differences between the intervention and control groups. A p value of <0.05 was considered as a significant difference.

Ethics

The study was approved by the Wuhan University Ethics Committee and the participating hospital. All eligible participants were informed about the purpose of the study, and voluntary consent was obtained.

Result

Characteristics of participants

The baseline data about the mothers are presented in Table 2, and the fathers' data are presented in Table 3. In the intervention group, the mothers' education at the “college or university” level was 77.8%, while the fathers' was 61.1%. The monthly income was similar in both groups. There were no differences regarding the characteristics of infants between the two groups.

Table 2.

Basic Socio-Demographic Characteristics of Mothers and Infants (n = 72)

Variable	Intervention group (n = 36)	Control group (n = 36)	t/Z/χ²	p
Age (years), M ± SD	28 ± 4.22	29 ± 2.878	1.371	0.101
Income (RMB)			−0.029	0.977
<1,000	7 (19.4%)	10 (27.8%)
1,000–2,999	10 (27.8%)	3 (8.3%)
3,000–4,999	11 (30.6%)	17 (47.2%)
≥5,000	8 (22.2%)	6 (16.7%)
Education level			−1.291	0.197
High school or below	7 (19.4%)	6 (16.7%)
College or university	28 (77.8%)	24 (66.7%)
Master or above	1 (2.8%)	6 (16.7%)
Newborn sex			1.399	0.237
Male	14 (38.9%)	19 (52.8%)
Female	22 (61.1%)	17 (47.2%)
Mean weight (g), M ± SD	3449 ± 360	3263 ± 424	2.008	0.454
Type of delivery			−0.737	0.461
Vaginal birth	11 (30.6%)	14 (38.9%)
Cesarean section	25 (69.4%)	22 (61.1%)

SD, standard deviation.

Table 3.

Basic Socio-Demographic Characteristics of Fathers (n = 72)

Variable	Intervention group (n = 36)	Control group (n = 36)	t/Z	p
Age (years), M ± SD	30 ± 4.72	31 ± 3.21	−0.876	0.384
Income (RMB)			−0.795	0.472
<1,000	0 (.0%)	0 (.0%)
1,000–2,999	1 (2.8%)	2 (5.6%)
3,000–4,999	9 (25.0%)	11 (30.6%)
≥5,000	26 (72.2%)	23 (63.9%)
Education level			−1.128	0.260
High school or below	7 (19.4%)	4 (11.1%)
College or university	22 (61.1%)	22 (61.1%)
Master or above	7 (19.4%)	10 (27.8%)

Attitude and knowledge of breastfeeding

Following the intervention, participants' breastfeeding attitude and knowledge improved remarkably, especially that of the fathers. As shown in Table 4, the mothers' scores after taking the IIFAS increased on the average by 6.33 points (p = 0.000), and the fathers' scores increased on average by 7.36 points (p = 0.000) compared with scores prior to the intervention. Moreover, breastfeeding knowledge level and the correct rate of BKS also increased significantly (p = 0.000). Mothers in the intervention group scored higher on the IIFAS and BKS than mothers in the control group did (IIFAS: 7.50 and 5.17, p = 0.001; BKS: 19.75 and 14.81, p = 0.009).

Table 4.

Breastfeeding Attitude and Knowledge Level Before and After Intervention (n = 72)

	IIFAS (average score)				BKS (average correct rate)
Participants	Before	After	t	p	Before	After	χ²	p
Intervention group
Mothers	61.50	69.00	10.439	0.000	70.37	90.12	12.500	0.000
Fathers	59.14	66.50	14.979	0.000	61.73	87.51	18.027	0.000
Control group
Mothers	61.81	66.98	12.686	0.000	72.23	87.04	6.903	0.009

Breastfeeding rate

As shown in Table 5, no difference was observed on breastfeeding initiation. At 1 month postpartum, the exclusive breastfeeding rates were similar, but fewer mothers in the intervention group chose formula feeding than did those in the control group (5.6% and 23.5%). At 4 and 6 months of age, 51.4% and 40% of mothers in the intervention group were exclusively breastfeeding their infants compared with 26.4% and 17.6% of mothers in the control group (p = 0.034; p = 0.041). The formula feeding rate of the intervention group at 6 months of age was significantly lower than that of the control group (20.0% and 44.1%, p = 0.032).

Table 5.

Prevalence of Breastfeeding at Different Postpartum Stages (n = 72)

	Intervention group, n (%)	Control group, n (%)	χ²	p
Breastfeeding initiation	14 (38.9)	12 (33.3)	0.241	0.624
Hospital discharge
Exclusive breastfeeding	14 (38.9)	12 (33.3)	0.241	0.624
Complementary feeding	21 (58.3)	19 (52.8)	0.225	0.635
Formula feeding	1 (2.8)	5 (13.9)	2.909	0.199
At 1 month^a
Exclusive breastfeeding	22 (61.1)	21 (61.8)	0.003	0.955
Complementary feeding	12 (33.3)	5 (14.7)	1.108	0.293
Formula feeding	2 (5.6)	8 (23.5)	4.613	0.032
At 4 months^b
Exclusive breastfeeding	18 (51.4)	9 (26.4)	4.510	0.034
Complementary feeding	12 (34.3)	15 (44.1)	0.700	0.403
Formula feeding	5 (14.3)	10 (29.4)	2.319	0.128
At 6 months^b
Exclusive breastfeeding	14 (40.0)	6 (17.6)	4.186	0.041
Complementary feeding	14 (40.0)	13 (38.2)	0.023	0.881
Formula feeding	7 (20.0)	15 (44.1)	4.619	0.032

Two mothers missing from the control group.

One mother missing from the intervention group.

Fathers' support of breastfeeding

The majority of mothers in the two groups claimed that the attitude of their partner toward breastfeeding was positive and supportive.

How the fathers supported breastfeeding was quite different. Mothers in the intervention group stated that their partners knew how to support breastfeeding because of the breastfeeding education session. They took care of the infant and did some housework in a positive manner. When mothers faced breastfeeding-related challenges, they received solid support from their partners to continue breastfeeding. Mothers in the control group complained that their partners wanted to offer assistance but did not know how to do this. When mothers encountered difficulties during the breastfeeding process, their partners could not provide positive support or correct knowledge.

Discussion

This is the first quasi-experiment study in China to explore the father's significant role in supporting successful exclusive breastfeeding. Mothers' breastfeeding behaviors were strongly associated with family perception, especially the support from the infants' fathers, which was shown to be beneficial for the initiation and duration of breastfeeding.¹⁷ Women appreciated the support from their partners while facing unexpected challenges during breastfeeding.¹⁹

Fathers' involvement in educational intervention improves parental knowledge and attitude toward breastfeeding

After the intervention, participants' breastfeeding knowledge level and breastfeeding attitudes were increased significantly, especially for fathers. The education program, which provided basic information on breastfeeding techniques, empowered fathers to be confident and to assist their partners. Participants in the intervention group adopted the content from the “father support” model, which resulted in a better understanding of what constituted a father's support in breastfeeding practices. The fathers were known to make decisions with the mothers on feeding patterns and provide both physical and emotional support to their partners.

Fathers' involvement in educational intervention prolongs the duration of exclusive breastfeeding

The unique finding in this study was that fathers influenced the duration of exclusive breastfeeding. Previous studies conducted in China found that the duration of exclusive breastfeeding was below the WHO breastfeeding goal.³³ Breastfeeding successfully continues when partners offer understanding and supportive beliefs about breastfeeding to support new mothers.³⁴ Additional research findings have indicated that partners could influence a woman's confidence in breastfeeding, and that mothers with positive support from their partners had higher confidence in breastmilk production and higher breastfeeding self-efficacy and babies had a greater chance of being breastfed exclusively to 6 months of age.^35,36 Therefore, if the infant's father has correct breastfeeding knowledge and supports his partner in using a scientific feeding method, the duration of exclusive breastfeeding will be extended.

Mothers appreciate fathers' support

One of the most important resources to promote breastfeeding is a mother's perception of the father's attitude.³⁷ Fathers play a crucial role in encouraging their partners to breastfeed²⁶ and influence a mother's feeding decision and the continuation of breastfeeding.^36,38 Mothers who experienced positive and active support from their partners showed higher confidence in their ability to breastfeed than did those with partners who were ambivalent or negative toward breastfeeding.^35,37 In agreement with Datta et al.,³⁹ the current study found that partners' infant feeding knowledge could influence mothers' decisions to initiate and continue breastfeeding, but fathers in the control group did not know how to provide support during specific breastfeeding challenges. Findings suggest that a good way to improve breastfeeding rates is to educate expectant mothers and fathers together.

Limitations

This study was limited to a single hospital setting, and most of the participants were of a higher socioeconomic group and education level. The intervention had different outcomes among participants from different social backgrounds. The sample size of this study is also smaller than other similar studies in Western society.^22,33 This study was not a pure randomized controlled trial, since the participants were recruited by time sequence. However, this method avoids information exchange in different groups.

Conclusions

The exclusive breastfeeding rate is increased by the involvement of fathers. It is recommended that health professionals in maternity units and community health centers be well armed with breastfeeding knowledge and skills. Simple education classes should be conducted on a regular basis to both mothers and fathers in order to increase the rate of exclusive breastfeeding.

Footnotes

Acknowledgements

We are especially grateful to the mothers and fathers who participated in this study, and give our thanks to Professor Shu Zhou for assistance on statistical analysis and Professor Sharon Redding for the professional review.

Disclosure Statement

No competing financial interests exist.

References

World Health Organization. Maternal, newborn, child and adolescent health. Breastfeeding. www.who.int/maternal_child_adolescent/topics/child/nutrition/breastfeeding/en/ (accessed March 20, 2015).

UNICEF, WHO, UNESCO, et al.. Facts for life. 4th ed., vol. 47–59. www.unicef.org/publications/files/Facts_for_Life_EN_010810.pdf (accessed March 20, 2015).

World Health Organization. Nutrition. Global nutrition targets 2025: policy brief series. www.who.int/nutrition/publications/globaltargets2025_policybrief_overview/en/ (accessed March 20, 2015).

China State Council. The outline program for development of Chinese women and children. www.gov.cn/zhengce/content/2011-08/05/content_6549.htm (accessed March 20, 2015).

World Health Organization. 10 facts on breastfeeding. www.who.int/features/factfiles/breastfeeding/en/ (accessed March 20, 2015).

UNICEF. China, Statistics, Nutrition. www.unicef.org/infobycountry/china_statistics.html (accessed March 20, 2015).

Dai

, Guan

, Li

, et al. Psychometric properties of a mainland Chinese version of the Iowa Infant Feeding Attitude Scale among postpartum women in China. Contemp Nurse, 2013; 44:11–20.

Thulier

, Mercer

. Variables linked to breastfeeding duration. J Obstet Gynecol Neonat Nurs, 2009; 38:259–268.

Daly

, Pollard

, Phillips

, et al. Benefits, barriers and enablers of breastfeeding factor. PLoS One, 2014; 9:e88204.

10.

Bunik

, Shobe

, O'Connor

, et al. Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula?. Acad Pediatr, 2010; 10:21–28.

11.

, Qiu

, Binns

, et al. Breastfeeding in China: a review. Int Breastfeed J, 2009; 4:6.

12.

Liu

, Zhang

, Li

, et al. The association between cesarean delivery on maternal request and method of newborn feeding in China. PLoS One, 2012; 7:e37336.

13.

Swanson

, Power

. Initiation and continuation of breast feeding: theory of planned behavior. J Adv Nurs, 2005; 50:272–282.

14.

Britton

, McCormick

, Renfrew

, et al. Support for breast feeding mothers. Cochrane Database Syst Rev, 2007; 24:CD001141.

15.

Scott

, Binns

, Oddy

, et al. Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics, 2006; 117: e646–e655.

16.

Clifford

, McIntyre

. Who supports breastfeeding?. Breastfeed Rev, 2008; 16:9–19.

17.

Souza

, Souza

, Tocantins

. The use of social network methodological framework in nursing care to breastfeeding women. Rev Latino-Am Enfermagem, 2009; 17:354–360.

18.

Ekstrom

, Widstrom

, Nissen

. Breastfeeding support from partners and grandmothers: perceptions of Swedish women. Birth, 2003; 30:261–266.

19.

Nickerson

, Sykes

, Fung

. Mothers' experience of fathers' support for breast-feeding. Public Health Nutr, 2012; 15:1780–1787.

20.

Sherriff

, Hall

. Engaging and supporting fathers to promote breastfeeding: a new role for health visitors?. Scand J Caring Sci, 2011; 25:467–475.

21.

Mitchell-Box

, Braun

. Fathers' thoughts on breastfeeding and implications for a theory-based intervention. J Obstet Gynecol Neonat Nurs, 2012; 41:E41–E50.

22.

Maycock

, Binns

, Dhaliwal

, et al. Education and support for fathers improves breastfeeding rates: a randomized controlled trial. J Hum Lact, 2013; 29:484–490.

23.

Susin

LRO

, Giugliani

ERJ

. Inclusion of fathers in an intervention to promote breastfeeding: impact on breastfeeding rates. J Hum Lact, 2008; 24:386–392.

24.

Bich

, Hoa

, Målqvist

. Fathers as supporters for improved exclusive breastfeeding in Viet Nam. Matern Child Health J, 2013; 18:1444–1453.

25.

Wolfberg

, Michels

, Shields

, et al. Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Am J Obstet Gynecol, 2004; 191:708–712.

26.

, Li

, Ma

, et al. Perceived family perceptions of breastfeeding and Chinese new mothers' breastfeeding behaviors. Sex Reprod Healthc, 2011; 2:143–147.

27.

De la Mora

. The Iowa Infant Feeding Attitude Scale: analysis of reliability and validity. J Appl Soc Psychol, 1999; 29:2362–2380.

28.

Sittlington

, Stewart-Knox

, Wright

, et al. Infant-feeding attitudes of expectant mothers in Northern Ireland. Health Educ Rese, 2007; 22:561–570.

29.

, McGrath

. A Chinese version of Iowa Infant Feeding Attitude Scale: reliability and validity assessment. Int J Nurs Stud, 2011; 48:475–478.

30.

Ouyang

, Xu

, Zhang

. Survey on breastfeeding among Chinese female physicians and nurses. Nurs Health Sci, 2012; 14:298–303.

31.

Sherriff

, Panton

, Hall

. A new model of father support to promote breastfeeding. Commun Pract, 2014; 87:20–24.

32.

World Health Organization. Indicators for assessing infant and young child feeding practices. Part I: Definitions. www.who.int/nutrition/publications/infantfeeding/9789241596664/en/ (accessed April 10, 2015).

33.

Guo

, Fu

, Scherpbier

, et al. Breastfeeding rates in central and western China in 2010: Implications for child and population health. Bull World Health Organ, 2013; 91:322–331.

34.

Rempel

, Rempel

. The breastfeeding team: the role of involved fathers in the breastfeeding family. J Hum Lact, 2011; 8:115–121.

35.

Pisacane

, Continisio

, Aldinucci

, et al. A controlled trial of the father's role in breastfeeding promotion. Pediatrics, 2005; 116:e494.

36.

Tohotoa

, Maycock

, Hauck

, et al. Dads make a difference: an exploratory study of paternal support for breastfeeding in Perth, western Australia. Int Breastfeed J, 2009; 13:15.

37.

Mannion

, Hobbs

, McDonald

, et al. Maternal perceptions of partner support during breastfeeding. Int Breastfeed J, 2013; 8:4.

38.

Vaaler

, Castrucci

, Parks

, et al. Men's attitudes toward breastfeeding: findings from the 2007 Texas Behavioral Risk Factor Surveillance System. Matern Child Health J, 2011; 15:148–157.

39.

Datta

, Graham

, Wellings

. The role of fathers in breastfeeding: decision-making and support. Br J Midwifery, 2012; 20:159–167.