Made to Feel Like Less of a Woman: The Experience of Stigma for Mothers Who Do Not Breastfeed

Abstract

Background:

Breastfeeding has become the recognized standard for good parenting, with social costs for not breastfeeding, but not every mother wants to or is able to breastfeed.

Objectives:

This study investigated social and personal costs with no breastfeeding.

Materials and Methods:

An in-depth survey was conducted with 250 mothers with infants who were not breastfeeding. Situated in the Framework Integrating Normative Influences on Stigma model for stigma, the study analyzed internalized stigma and perception of stigma from others, maternal feelings of warmth for the infant, and hiding formula use.

Results:

Mothers who chose not to breastfeed reported little personal or public stigma. In comparison, mothers who were unable to breastfeed experienced relatively more internalized stigma and perceived that other people saw them as failures. Mothers who experienced more internalized and perceived social network stigma were likely to hide use of infant formula from others and had lower feelings of warmth for their infants. Knowledge about formula use and availability of support resulted in less stigma and more warmth for the infant.

Conclusions:

These results suggest that public responses causing a mother to feel guilty for using infant formula result in negative feelings of self-worth and dysfunctional maternal behaviors.

Introduction

While 83% of mothers in the United States initiate breastfeeding, breastfeeding initiation, duration, and exclusivity continue as problems globally and in the United States. In high-income countries, more than one in five babies are never breastfed.¹ The Baby-Friendly Hospital Initiative developed to improve breastfeeding initiation, duration, and exclusivity has had some limited success.² Fallon and colleagues reported, “more than 15,000 facilities in 152 countries have been awarded Baby-Friendly status.”^3(p2) Even so, duration and exclusivity of breastfeeding fall short of goals identified by health agencies such as the World Health Organization, the American Pediatrics Association, UNICEF, and the Centers for Disease Control (CDC).⁴ As a case in point, the CDC reported that while 60% of American infants continue to be breastfed at 6 months of age, only 25% are breastfed exclusively resulting in suboptimal breastfeeding.⁴

Given the high rate of breastfeeding initiation in the United States, if a mother does not want to or is unable to breastfeed, other people may think that she is a “bad” mother.^5,6 Health care advocates promote breastfeeding as the gold standard as breast milk has properties shielding the infant from health threats.^7,8 This suggests that women who cannot breastfeed, or who elect not to do so, are giving their infants a substandard substitute.⁹ This paves the way for self-blame and potentially robs women of their authority to be the decision makers for their infants' nutritional needs.^10,11 For example, Fallon and colleagues found that a high percentage of formula feeding mothers experienced guilt and stigma because of their feeding choice.¹² Meisenbach defined stigma as perception of behaviors that have problematic physical, social, and moral consequences.¹³ Stigma is communicated through verbal and nonverbal messages and behaviors such as discrimination and exclusion. This study used the Framework Integrating Normative Influences on Stigma (FINIS)¹⁴ to examine three levels of stigma experienced by women for not breastfeeding. The study compared social and personal stigma experienced by mothers who chose to use infant formula with mothers who were not able to breastfeed.

A model for stigma

Pescosolido and colleagues¹⁴ proposed the FINIS model based on micro, meso, and macro levels. The micro level focuses on personal characteristics leading to stigma. The meso level is associated with public perceptions about when to assign stigma, whereas the macro level is concerned with normative beliefs governing a particular behavior. In the case of breastfeeding, the micro level focuses on how women internalize stigma associated with not breastfeeding. The meso level is how other people react to mothers who do not breastfeed. The macro level focuses on social expectations about breastfeeding.

Some breastfeeding research has indicated that women who do not breastfeed experience social stigma and discrimination. For example, Hvatum and Glavin found that mothers in Norway tended to be fearful about breaking social expectations using formula.¹⁵ Ogbonna et al. found in Nigeria that pride in motherhood through breastfeeding outweighed inconvenience and discomfort.¹⁶ However, most previous studies of stigma for formula use are qualitative and have not examined how different sources of stigma influences mothers' feeding behaviors. This research aims to bridge this gap.

Several studies have examined negative reactions to using infant formula. For example, Guell and colleagues¹⁷ reported that women who used infant formula either because they chose to do so or were not able to breastfeed found that their health care providers were reluctant or unable to share necessary information on infant formula use or, alternatively, the information given was either oversimplified or wrong. In some cases, when formula-fed infants experienced rapid weight gain, health providers did not give helpful advice to concerned mothers.¹⁸ Because breastfeeding is the medically endorsed option, parents who use formula often lack informational support and have to rely on manufacturer's instructions for how to use their product.⁵ Trickey and Newburn¹⁹ argued for supporting a mother's choice throughout her infant feeding journey whether the mother is breastfeeding or using formula suggesting that mother-centered support means a balance of information about formula and breastfeeding. They advocated that breastfeeding counselors should support maternal infant feeding choice considering each mother's specific challenges.

Previous studies reported that women feel more attachment to their infants if they breastfeed.²⁰ Based on Mercer's Maternal Role Attainment Theory,²¹ five concepts promote bonding between mother and child—maternal characteristics such as empathy and self-esteem, infant characteristics such as temperament and responsiveness, maternal identity and competence, and maternal gratification and attachment. The final dimension includes child cognitive development, behavioral health, and social competence. Fallon and colleagues conducted an in-depth study of 890 formula-feeding mother–infant dyads.²² While 46% of mothers in their study started out breastfeeding, they did not ask whether any participants chose not to breastfeed or were unable to breastfeed. They found that mothers who used formula often reported dissatisfaction with their feeding choice. They often are asked why they are not breastfeeding, prompting some to avoid using formula in public.⁶

Fahlquist²³ assessed emotions experienced by a sample of 47 mothers who did not breastfeed (they did not distinguish between choice and inability in this study). Their participants reported experiencing depression, failure, loss of freedom, and guilt.¹⁹ Health messages include one-way transmission of information promoting benefits of breastfeeding and do not attend to individual autonomy. In a “breast is best” environment, nonbreastfeeding mothers feel blameworthy and inadequate. Given previous studies on stigma and reasons for not breastfeeding, closeness to one's infant, and maternal autonomy, the following questions were investigated.

RQ1: To what extent do women who do not breastfeed experience micro, meso, and macro levels of stigma?

RQ2: Are there differences in stigma experienced by women who choose not to breastfeed and those who are not able to breastfeed?

RQ3: What is the relationship between connection with the infant, hiding use of formula from others, and perceptions of micro, meso, and macro stigma?

RQ4: What do people say to mothers who use formula? Is there a difference in stigma based on whether a mother chooses not to breastfeed or is not able to breastfeed?

Materials and Methods

Participants and procedures

A sample of 250 mothers who did not breastfeed was recruited using Qualtrics Research Suite™. In compliance with the institutional research board at Michigan State University, human subjects' consent was obtained before conducting this study (MSU protocol 2452, exempt review obtained April 3, 2019). Infants ranged in age from newborn to 9 months. The average age of mothers was 31.71 (standard deviation [SD] = 7.40), and 60% of participants (n = 150) had two or more children. We asked participants whether they chose not to breastfeed or whether they or the infant was not able to breastfeed. Eighty-one mothers reported that they chose to use formula rather than breastfeed, 125 were not able to breastfeed, and 17 said that their baby was not able to breastfeed. Other reasons included poor milk production, difficulty latching, maternal medication and diseases, infant allergies to breast milk, inverted nipples, excessive pain, adoption, a premature baby in the Neonatal Intensive Care Unit (NICU), returning to work, and convenience. Participant characteristics are presented in Table 1.

Table 1.

Characteristics of the Sample

	Number of participants	Percent
Education
No HS diploma	12	4
HS graduate	98	40
Career training	19	7
2-year college	54	21
4-year college	47	0
Advanced degree	20	8
Income ($33,000 average)
$25,000–33,000	106	42
$35,000–50,000	84	34
$50,000–75,000	50	20
$75,000–100,000	10	4
Cesarean delivery	86	34
Baby born in BFH	240	96
Employment status
At-home mother	140	56
Employed part time	40	16
Employed full time	70	28
Number of children
1 child	98	40
2 children	74	30
3 children	33	13
4 children	30	12
5 or more children	13	5
Maternal support	M	SD
Husband/partner	6.1	1.9
Mother/mother-in-law	5.9	1.9
Medical provider	5.5	1.9
Friend	5.7	1.8
Coworker	5.2	2.2
Social network support	5.1	2.3

BFH, Baby-Friendly Hospital; SD, standard deviation.

Measures

Measures were 7-point Likert scales ranging from 1 (strongly disagree) to 7 (strongly agree). Confirmatory factor analyses using LISREL²⁴ derived one-factor solutions before computing composite scores. Cronbach's alpha assessed reliability. Bivariate correlations are presented in Table 2. The full scales are available from the corresponding author.

Table 2.

Bivariate Correlations

	1	2	3	4	5	6	7	8
1. Micro stigma	2.07 (1.42)
2. Meso stigma	0.38^**	4.02 (1.60)
3. Macro stigma	0.39^**	0.62^**	3.43 (1.71)
4. Warmth with baby	−0.37^**	−0.02	−0.09	6.31 (1.14)
5. Hiding formula	0.60^**	0.21	0.36^**	−0.41^**	1.88 (1.33)
6. Bottle-feeding education	−0.13^*	−0.09	−0.06	0.09	−0.02	4.48 (1.70)
7. Baby-Friendly Hospital	−0.09	0.07	−0.09	0.33^**	−0.34^**	0.13^*	5.93 (1.13)
8. Support for bottle-feeding	−0.18^*	−0.01	−0.04	0.25^**	−0.25^**	0.03	0.19^**	5.50 (1.52)

All values are < .05 or < .001. None were at the < .01 level.

Mean scores and deviations are displayed on the diagonals.

p < 0.05.

p < 0.001.

Feelings of warmth toward the baby

This scale consisted of six items²⁵ (M = 6.31, SD = 1.14, α = 0.94). Sample items included (1) I feel close to my baby when I am bottle-feeding; and (2) I feel happy bottle-feeding my baby.

Hiding use of formula feeding

This variable was measured with six items²² (M = 1.88, SD = 1.33, α = 0.92). Sample items included (1) I try to hide bottle-feeding because of what other people will say; and (2) I do not tell other people that I bottle-feed my baby.

Pescosolido and colleagues developed the FINIS model to study mental illness stigma.¹⁴ This is the first study to situate the FINIS model in the context of women who do not breastfeed.

To measure the micro level we developed items to assess how mothers reacted to criticism about use of infant formula and how they internalized guilt and shame for not breastfeeding. We developed items to measure the macro level focusing on the interpersonal communication of stigma from other people. The final set of items was developed to assess perception of social norm violation and threat to accepted standards of maternal behavior. Items measuring micro stigma, meso stigma, and macro stigma were showing good model fit, χ² = 68.18, p = 0.031, CFI = 0.97, RMSEA = 0.04. Table 3 reports factor loadings for the three factors of stigma.

Table 3.

Factor Loadings of Micro, Meso, and Macro Levels of Stigma

Statement	Micro	Meso	Macro
Micro
I feel guilty because I bottle-feed.	0.82	0.13	0.16
I feel ashamed because I bottle-feed.	0.90	0.14	0.11
I feel inadequate because I bottle-feed.	0.81	0.18	0.21
I feel embarrassed because I bottle-feed.	0.83	0.22	0.08
I feel regret bottle-feeding.	0.81	0.08	0.09
Meso
It makes me angry that other people judge me for bottle-feeding.	−0.003	0.63	0.27
I am often asked why I am not breastfeeding.	0.16	0.76	0.17
People regularly tell me that “breast is best.”	0.16	0.65	0.16
I am sick and tired of people who criticize me for bottle-feeding.	0.11	0.73	0.33
Other people make me feel like a failure as a mother because I bottle-feed.	0.38	0.58	0.32
Macro
Mothers who do not breastfeed are treated badly by other people.	0.17	0.29	0.74
People think that not breastfeeding means that a mother has a weak character.	0.18	0.29	0.84
Other people think that a woman who does not breastfeed her baby is not motherly.	0.18	0.29	0.86
A woman is thought of as a bad mother if she bottle-feeds her baby.	0.20	0.22	0.83

Bold values show factor loadings.

Micro stigma was measured with five items developed by the authors (M = 2.07, SD = 1.42, α = 0.93). Sample items included (1) I feel guilty because I bottle-feed; and (2) I feel inadequate because I bottle-feed.

Meso stigma was measured with five items developed by the authors (M = 4.02, SD = 1.60, α = 0.85). Sample items included (1) Many people show bias against me for bottle-feeding; and (2) Other people make me feel like a failure as a mother because I bottle-feed.

Macro stigma was measured with five items developed by the authors (M = 3.43, SD = 1.71, α = 0.91). Sample items included (1) People expect that a mother should breastfeed her child instead of using infant formula; and (2) A woman is considered a bad mother if she does not breastfeed her baby.

In addition, the study measured education about formula use and availability of support.

Education about formula use

This variable was measured with four items (M = 4.48, SD = 1.70, α = 0.76).²⁵ Sample items included (1) Health care professionals at the hospital told me about bottle-feeding right after my baby was born; and (2) Health care professionals at the hospital helped me learn how to bottle-feed my baby.

Availability of support

Support was assessed with 14 items, including 7 sources, including spouse, mother, mother-in-law, doctor, friends, support group, and coworkers.²⁶ Amount of support from each of these seven sources was assessed with a single item ranging from 1 indicating “no support at all” to 7 indicating “a lot of support” (M = 5.50, SD = 1.52).

Coding scheme

Participants listed up to three comments from other people about not breastfeeding. The coding scheme included eight categories (1) opposition to formula, (2) approval of formula, (3) support of breastfeeding, (4) advantages of breastfeeding, (5) advantages of formula, (6) indifference to the mother's decision, (7) judgmental comments, and (8) other. Two coauthors coded 15% of the responses to establish intercoder reliability calculated using Krippendorff's alpha 0.82.²⁷ They then divided the remaining comments and completed coding.

Results

Forty-four percent of mothers had to learn correct formula use on their own. As shown in the mean scores in Table 1, they reported moderate-to-strong family and provider support for their infant feeding decision. All mean scores were significantly higher than the scale mid-point, ts > 8.75, ps < 0.001. The majority agreed that Baby-Friendly designated hospitals were a good idea (M = 6.13, SD = 1.09), significantly higher than the scale mid-point, t(249) = 30.84, p < 0.001. Use of formula was not associated with education or income. RQ1 asked whether there were differences in the level of stigma. Mean scores for micro stigma (M = 2.07, SD = 1.42) and macro stigma (M = 3.43, SD = 1.71) were significantly below the scale mid-point, t(249) _{micro stigma} = −21.53, p < 0.001, and t(249) _{macro stigma} = 5.31, p < 0.001. Paired sample t-tests showed that participants' meso stigma was higher than micro stigma t(249) = 18.23, p < 0.001 and macro stigma, t(249) = 6.47, p < 0.001. This result suggests that mothers who did not breastfeed reported feeling stigma from other people in their network.

RQ2 compared women who chose not to breastfeed (n = 81) with those who could not breastfeed (n = 142). Results from analysis of variance showed that participants who could not breastfeed (M = 2.25, SD = 1.51) perceived a higher level of micro stigma, F(1, 221) = 4.92, p = 0.028, η² = 0.02, compared to women who chose not to breastfeed (M = 1.80, SD = 1.27). Participants who were unable to breastfeed (M = 4.27, SD = 1.56) also perceived a higher level of meso stigma, F(1, 221) = 4.53, p = 0.034, η² = 0.02. The difference between these two groups was not significant for macro stigma, F(1, 221) = 0.68, p = 0.41, suggesting that both groups experienced social stigma.

RQ3 asked whether the three kinds of stigma affected feelings of connection with infants and intention to hide formula use. Ordinary Least Square regressions were conducted with connection to the infant and hiding formula use as the criterion variables and mean-centered levels of stigma as predictors. The model for connection was statistically significant, F(3, 246) = 14.50, p < 0.001, adj. R² = 0.14. Micro stigma was negatively associated with connection with the infant, β = −0.41, t = −6.35, p < 0.001. Meso stigma was positively associated with connection, β = 0.15, t = 1.98, p < 0.05, while macro stigma was not associated with connection, β = −0.03, t = −0.33. This result suggested that mothers who internalized stigma for not breastfeeding felt less connection with their infant.

The regression model for hiding formula use was statistically significant, F(3, 246) = 51.83, p < 0.001, adj. R² = 0.38. Hiding formula use was positively associated with micro (β = 0.56, t = 10.21, p < 0.001) and macro stigma (β = 0.22, t = 3.44, p < 0.01) and negatively associated with meso stigma (β = −0.15, t = −2.25, p < 0.05). This finding suggested that the more internalized social stigma for not breastfeeding, the stronger mother's intention to hide use of formula.

As for RQ4, participants were asked to list three comments when other people discovered they were using infant formula. In total, participants listed 702 comments. About one third of comments showed indifference to infant feeding choices. One hundred fifty-one comments (21.5%) supported use of infant formula. Just over 23% of comments were critical of the mother's choice to use infant formula. One hundred sixteen comments (16.6%) opposed formula, and 46 (6.5%) mentioned the relative advantages of mother's milk over formula.

Discussion

This study framed the decision to not breastfeed in a model for three levels of stigma on feelings of connection with the infant and hiding formula use. The study revealed that mothers who chose not to breastfeed reported little personal (micro) or network (meso) stigma. In comparison, mothers who were not able to breastfeed experienced more self-stigma and perceived that others viewed them as failures. They were likely to hide formula use and had lower connection with their infants. One quarter of comments reported from other people were openly critical of use of infant formula. These results are consistent with prior research on stigma associated with not breastfeeding.^28,29 Women who internalized stigma wanted to hide formula use because they feared negative judgment. Stigma for not breastfeeding may result in dysfunctional behavior and internalized stigma. Both breastfeeding and formula feeding mothers need public support for their infant feeding choices.

The American College of Obstetricians and Gynecologists advocates that while breastfeeding confers advantages, “each woman is uniquely qualified to make an informed decision surrounding infant feeding.”³⁰ Even with this expert endorsement, many mothers recognize that using formula is suboptimal and that breastfeeding is superior.^31,32 Internalized stigma derives from the belief that using formula is second best.³³ Faircloth described that infant feeding choices are “the most conspicuously moralized element of mothering.”^34(p358) Mothers who do not breastfeed, either because of choice or inability, desire affirmation but often are marginalized and criticized for putting their infant at health risk.³⁴ Mothers in the maternal-infant dyad need to “balance personal, social family, and financial factors in infant feeding choices.”^35(pE8)

An important contribution of this study is that it systematically investigated a large sample of nonbreastfeeding mothers probing their experience of stigma at three levels. Analysis of the micro level showed that mothers who cannot breastfeed experience guilt and anxiety that need to be addressed through assurance and support that they are good mothers and that their formula-fed infants will be able to thrive. Analysis of meso stigma showed that other people judge and are open in their criticism of mothers who do not breastfeed. The fed is best message is gaining a foothold in the public imagination but needs more endorsement and public support. The macro level has shown a shift in public norms away for formula use in the 1950s and 1960s and a return to breastfeeding. Even though the norm has shifted, maternal agency in infant feeding choices must be respected in a climate endorsing breastfeeding. A dilemma for health care providers is that in advocating exclusive breastfeeding as a best practice, they may stigmatize mothers who do not breastfeed.^35,36 It is imperative for health care providers to instruct mothers on how to use formula (tenet 9 of “Baby-Friendly” guidelines).² As an illustration of the need to destigmatize formula, there are many online support groups such as the Fed is Best Foundation, Fearless Formula Feeding, and Guilt-Free Bottle Feeding.

This study reported nonbreastfeeding women's experience of stigma at only one point in time rather than longitudinal tracking perceptions of stigma. No measure of public reactions to women who do not breastfeed was taken. The extent to which there is disapproval for mothers who do not breastfeed and how this contributes to stigma needs further investigation. Given that the majority of mothers gave birth in “Baby-Friendly” designated hospitals, it would be informative to conduct a comparative study with nondesignated “Baby-Friendly” hospitals to assess whether breastfeeding promotion affects stigma. Future research might also benefit from focusing on mothers who use mixed-feeding methods to investigate whether they experience stigma.

Conclusions

Mothers reported acceptable levels of support for their infant feeding decisions. The majority agreed that “Baby-Friendly” designated hospitals were a good idea. Results showed that participants who could not breastfeed perceived a higher level of self-stigma and felt less connection with their infants. They were reluctant to reveal formula use fearing that they might be judged. About one quarter reported open criticism of their use of infant formula instead of mother's milk. Our results suggest that other people should respect that the mother is in the best position to determine the optimal feeding option for her infant.

Footnotes

Acknowledgments

The authors thank Dr. James Dearing of the Department of Communication at Michigan State University for finding money for us to compensate women for participating in this study. Without this subvention, we would not have been able to conduct this research.

Disclosure Statement

No competing financial interests exist.

Funding Information

Funding for this project was provided by the Department of Communication at Michigan State University, East Lansing, Michigan.

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