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Infant feeding intentions among first time pregnant women in urban Melbourne, Australia
Midwifery 29 (2013) 787–793
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Infant feeding intentions among first time pregnant women in urban Melbourne, Australia Elissa York, BHSc (Hons) (Research Assistant), Elizabeth Hoban, BA, MPH, PhD (Senior Lecturer)n Deakin University, 221 Burwood Highway, Burwood, Victoria 3152, Australia
a r t i c l e i n f o
abstract
Article history: Received 10 August 2011 Received in revised form 29 June 2012 Accepted 29 June 2012
Objective: to identify first time pregnant women’s infant feeding intentions for the first 2 years of life. Design: a qualitative phenomenological approach was used, with semi-structured interviews as the primary method of data collection. Setting: two of Eastern Health’s antenatal clinics in the outer east region of Melbourne, Australia. Participants: seven first time pregnant women from an Eastern Health antenatal clinic. Main outcome measure: women’s infant feeding intention for the first 2 years of life. Main findings: all the participants intend to breast feed their infant for around 6 months. Women rely heavily on information about infant feeding options from friends, books and the internet, as the information provided by health professionals was found to be inadequate, acquired late in the pregnancy and difficult to access. Key conclusions: the information women receive from midwives at antenatal appointments and parenting classes about infant feeding options is inadequate, as women are not satisfied with the timing, amount and usefulness of the information they receive. Implications for practice: in order to see an increase in the rate of breast feeding it is imperative to create supportive environments for women to breast feed, and for midwives and health professionals to provide information and continued support for women in both the pre- and postnatal period. Crown Copyright & 2012 Published by Elsevier Ltd. All rights reserved.
Keywords: Breast feeding Pregnancy Feeding intention Education
Introduction Breast feeding is widely acknowledged as the most optimal method of infant feeding as it ensures positive health outcomes, growth and development (Armstrong et al., 2002; Australian Breastfeeding Association, 2005; World Health Organisation, 2010a). For an infant, the obtainment of breast milk provides essential nutrients that act as a protective factor against chronic disease (UNICEF, 2008; Australian Government Department of Health and Ageing, 2010). For a mother, breast feeding reduces the risk of premenopausal breast and ovarian cancer, while assisting a woman return to her pre-pregnancy body shape more quickly (Australian Bureau of Statistics, 2001; National Health and Medical Research Council, 2003; Australian Breastfeeding Association, 2005; Commonwealth of Australia, 2007). The World Health Organisation (WHO) recommend exclusive breast feeding for the first 6 months of life, followed by continued breast feeding and the introduction of nutritious complimentary foods up to the age of 2 years or beyond (World Health Organisation, 2010b, 2011). These recommendations are supported in Australian by the
n
Corresponding author. E-mail address: [email protected] (E. Hoban).
National Health and Medical Research Council (Australian Government Department of Health and Ageing, 2009). In Australia in 2007, according to the Longitudinal Study of Australian Children (LSAC), 92 per cent of infants were breast fed at birth, however the rate of breast feeding was found to decline steadily with age (Australian Institute of Family Studies, 2008; Australian Government Department of Health and Ageing, 2009). At 1 month, 71 per cent of infants were being exclusively breast fed, and at 6 months just 14 per cent of infants were exclusively breast fed (Australian Government Department of Health and Ageing, 2009). At 2 years 5 per cent of infants were receiving any breast milk (Australian Institute of Family Studies, 2008; Australian Government Department of Health and Ageing, 2009). More recent data from the Australian Institute of Health and Wellbeing shows that 96 per cent or babies were initially breast fed, but just 15 per cent were exclusively breast fed for less than 6 months (Australian Government Institute of Health and Wellbeing, 2011). These figures are alarmingly low and far from the recommended infant feeding guidelines. Several factors intertwine and influence a woman’s infant feeding intention. Research shows that older maternal age, coinhabiting with a partner, being well educated and being employed part time positively influence a woman’s decision to breast feed (Donath et al., 2003; Haslam et al., 2003; Forster et al.,
0266-6138/$ - see front matter Crown Copyright & 2012 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2012.06.023
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2006; Chertok et al., 2010). As well, women who have supportive social networks, who have breast-feeding self-efficacy, and who are pregnant for the first time are more likely to intend to breast feed their infant (Lee et al., 2005; Meedya et al., 2010). Furthermore, a strong predictor of intention to breast feed is a woman’s own experience of breast feeding as a child; women who were breast fed themselves are more likely to intend to breast feed their infant (Humphreys et al., 1998; Donath et al., 2003; Mitra et al., 2004; Forster et al., 2006). A woman’s intention to breast feed is a strong predictor of breast-feeding behaviour (Donath et al., 2003; Jarman et al., 2008; Meedya et al., 2010). A British study conducted between April 1991 and December 1992 (n ¼10,548) found that prenatal intention to breast feed positively influenced a woman’s initiation and duration of breast feeding (Donath et al., 2003). Of the women who intended to breast feed for at least 4 months, 96.6 per cent of these women initiated breast feeding after birth (Donath et al., 2003). This is compared to women who intended to bottle feed, where just 3.4 per cent initiated breast feeding (Donath et al., 2003). The strength of the relationship between prenatal intention to breast feed and breast-feeding behaviour in the postnatal period is evident in these findings. Prenatal breast-feeding interventions, including participation in focus group and one-on-one discussions conducted by midwives has been found to effectively prolong breast-feeding duration (Rosen et al., 2008). A blind experimental design study conducted in Western Australia with primiparous women (n¼70) who intended to breast feed found that in the intervention group, where women attended teaching sessions about position and attachment of the baby, there were three times as many women breast feeding at 6 weeks postpartum and fewer women with nipple trauma compared to the non-intervention group (Duffy et al., 1997). A similar study was conducted in America (n ¼194) with women who intended to breast feed. The findings show that 54 per cent of women in the intervention group who received prenatal group or one-on-one breast-feeding education, were exclusively breast feeding at 4 months compared to 6.5 per cent in the control group (Rosen et al., 2008). This type of intervention provides evidence that antenatal education classes during pregnancy that focus on breast feeding has the potential to increase breast-feeding rates and duration. Despite this, prenatal midwifery support is yet to provide women with a sense of selfconfidence in their ability to breast feed their infants (Craig and Dietsch, 2010). Epidemiological studies indicate that women in Australia are not currently meeting the WHO recommendations regarding infant feeding practices. There has been little examination as to why this is the case and how different factors, such as the provision of relevant infant feeding information during pregnancy, and the influence that significant others’ have on women’s breast-feeding intention. To contribute to this gap in information a study was conducted with first time pregnant women living in an outer east region of Melbourne, Australia. The aim of the study was to examine women’s infant feeding intentions for the first 2 years of life. More specifically, the study was designed to understand first time pregnant women’s infant feeding intention, the factors that influence a woman’s infant feeding intention, and the perceived barriers to a woman’s intended infant feeding strategy.
Methods Study design A qualitative phenomenological approach (Liamputtong, 2009) was to examine infant feeding intentions of a small sample (n ¼7)
of first time pregnant women in the outer east region of Melbourne, Australia. Qualitative research, also referred to as social research, is focused on identifying the ‘why’, ‘how’ and ‘what’ questions about human views and behaviours (Neergaard et al., 2009). An imperative aspect of qualitative research is the extent to which in depth knowledge is acquired. In all qualitative research, the researcher not only wants to find out ‘what it is’, but of more importance, ‘explain to me – how, why, what’s the significance?’ (Hesse-Biber and Leavy, 2005). Phenomenology is a methodological theory most often used in qualitative research (Liamputtong, 2009). It is primarily concerned with understanding, describing and interpreting human behaviour in regards to personal experiences (Liamputtong, 2010). Sampling and settings Study participants were recruited from two of Eastern Health’s antenatal clinics in Melbourne using a purposive sampling strategy (Liamputtong, 2009, 2010). As well, participants were recruited using snowball sampling, i.e. one first time pregnant women referred the researcher to other women who met the selection criteria, outlined below (Liamputtong, 2009, 2010). Initial interest for participation in the study was gained through the circulation of a recruitment flier at both antenatal clinics; Box Hill and Yarra Ranges. In addition, the researcher attended each antenatal clinic during busy periods in order to approach women who were waiting for appointments. Women were invited to participate if they met the selection criteria. Women were eligible to participate if they were: pregnant for the first time; in the second or third trimester of pregnancy; and aged between 18 and 45 years. First time pregnant women were recruited to ensure they had no previous experience of infant feeding that would impact on their intention. It was imperative to recruit women who were in the second or third trimester of pregnancy to ensure women had had adequate time to consider infant feeding options; women in the first trimester may not have considered this yet. Women were excluded from the study if they were not pregnant for the first time, if they were in the first trimester of pregnancy, or if they were aged outside the specified age criteria. Data collection The main method of collecting qualitative data was the use of in-depth face-to-face interviews, lasting approximately 1 hr (Liamputtong, 2010). Each interview was conducted on a oneoff basis and used a semi-structured interview guide to ensure that key topic areas were discussed with each woman, yet allowing for flexibility during each interview (Liamputtong, 2009). Taylor (2005) suggests that the aim of an in depth interview is to ‘explore the ‘insider perspective’, to capture, in the participants own words, their thoughts, perceptions, feelings and experiences’ (Taylor, 2005). The interviews were conducted at the antenatal clinic or at a nearby location. Throughout the interviews, the investigator was able to take note of the language, phrases, and tone that each woman used to explain their experience and perceptions of their own infant feeding intention. Each interview was audio-recorded and transcribed verbatim by the first author; this acted as the preliminary stage of data analysis (Liamputtong, 2009). Each participant was allocated a code to maintain participant anonymity. This ensured the data was de-identified and not recognisable. The use of semi-structured interviews was particularly important to allow the investigator to ‘elicit information from prepared questions, but at the same time allow the participants to elaborate on their responses’ (Liamputtong, 2010, p. 47). The use of the
E. York, E. Hoban / Midwifery 29 (2013) 787–793
semi-structured interview guide ensured key topic areas were discussed, yet allowed for flexibility within each interview. A critical element of semi-structured interviews was the use of probes to direct and prompt the participant in order to establish a clear and more in depth understanding of their infant feeding intention (Liamputtong, 2009). Data analysis Thematic data analysis was used to adequately identify common themes that reflected the textual data. It was imperative that the researcher conduct and transcribe interviews to ensure knowledge of the data in order to report accurate and insightful findings. (Howitt and Cramer, 2007; Liamputtong, 2009). The use of thematic analysis allowed themes to be identified and analysed within the data set (Liamputtong, 2009). Preliminary analysis was undertaken by the first author and then by the co-author. Constant comparative analysis was then carried out, and only themes identified through paired consensus were included. Data was coded, and pseudonyms were used to maintain participant anonymity (Liamputtong, 2009). Four major themes were developed during the analysis process and they are the focus of this paper: infant feeding intention; factors that influence infant feeding intention; barriers to successful breast feeding; and infant feeding information sources.
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Table 1 Participant demographics. Characteristics Age (mean)
N¼7 27
Country of birth Australia Other
6 1
Marital status Married Partnered
6 1
Education University TAFE Year 11
4 2 1
Employment Full-time Part-time None
2 4 1
Household annual income o $30,000 $30,000–50,000 $50,000–70,000 $70,000–90,000 $90,000 þ
3 1 2 1 0
Breast fed by own mother Current smoker YES NO
7 0 7
Ethics This study adhered to the ethical standards set out in the National Statement on Ethical Conduct in Human Research (Australian Government, 2007). Ethics approval for this study was granted in June 2010 by both the Eastern Health Research and Ethics Committee (EC00211) and the Deakin University Human Research Ethics Committee (EC00213).
Findings Seven first time pregnant women provided written informed consent and were recruited for the study. All the women were in the second or third trimester of pregnancy, ranging between 13 and 39 weeks, and were aged between 23 and 30 years. Six of the participants were married and one was casually dating the father of her child. Four of the participants had university qualifications, two had TAFE qualifications, and one had completed up to Year 11 at school. Demographic details of the participants are outlined in Table 1. Fig. 1 is a visual representation of the major and minor themes that emerged from data analysis: infant feeding intention, factors that influence infant feeding intention, infant feeding information sources and barriers to successful infant feeding. These will be discussed in detail below. Infant feeding intention All of the participants intended to breast feed their infant and none of the women intended to use infant artificial milk from the outset. Despite this, women were aware that breast feeding would be challenging and they may need to utilise infant artificial milk to maintain infant health. Women said that they seldom considered how long they would exclusively breast feed, if they would use an infant artificial milk, or at what age they would introduce complimentary food into their infant’s diet: I intend on breastfeeding.. as long as it all works.. if everything works out I will breastfeed [27 years, university educated, employed part time, married]
In terms of how long I breast feed.. I think I’ll have to play it by ear, I’m sort of of the philosophy, we’re mammals, you breastfeed because the baby doesn’t have any other way of getting nutrients, once they do have other ways then you have your transition period and then you get them on to solids [30 years, TAFE educated, employed part time, married] The main reasons women gave to support their intention to breast feed include the numerous health benefits associated with breast feeding for both the mother and child, as well as the knowledge that breast feeding is recommended by midwives and the medical profession as the most optimal way to feed an infant. All women felt that feeding an infant with artificial milk is portrayed as second best by health professionals and the media, and for this reason they felt pressure from the community to breast feed their child. Women said they would feel a sense of guilt and failure if they had to use infant artificial milk: It’s sort of like if it doesn’t work out then you can fall back on this, but it’s sort of portrayed as you know if you can you should be breastfeeding [29 years, university educated, employed part time, married] ..it is always very much second besty.you would feel a bit of guilt or failure or something definitely..[23 years, university educated, employed part time, married] If I have difficulties I’m happy to use formula, or if I need to top up, I’m happy to go down that rack if I have to but I would prefer not to if I don’t have to [29 years, university educated, employed full time, married] Few women had considered the introduction of complimentary food into their child’s diet. A common notion was that the introduction of complimentary food would be guided by advice provided to them by doctors and midwives in the postnatal period. Women had more often thought about the types of food they would like to introduce into their child’s diet; however they had not considered the timing of the introduction of solids. The types of foods women planned to introduce into their child’s diet
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Childhood
Partner
Knowledge
Own Experience
Factors that Influence Infant Feeding Intention
Friends
Food
Breastfeeding Infant Feeding Intention
Infant Formula
Complimentary Food Friends
Work and Study
Barriers to Successful Infant Feeding
Pain
Infant Feeding Information Sources
Hospital and Clinic
Male Friends Internet and Books Community Acceptance
Antenatal Class
Fig. 1. Major and minor themes that emerged from data analysis.
included predominately home cooked vegetables and fruit. Home prepared complimentary foods were preferred to commercial baby foods; however women said they would purchase commercial baby foods occasionally for the purpose of convenience:
was highly valued, but overall, attitudes towards breast feeding by a woman’s partner, family and friends were found to be more influential on her intention to breast feed, rather than her own experience of being breast fed as a child:
I think I’d like to do my own at home yeah, I imagine I will buy some out of convenience but more so I would prefer to do it at home [29 years, university educated, employed full time, married]
I have one particular close friend..she’s been a great resource for me.. and because it’s recent as opposed to my mum which is 30 years ago, a lot of the knowledge has changed in that time.. but in my family that’s sort of been the standard I guess (breastfeeding) unless there’s been a problem.. and I think the same in my husbands family [30 years, TAFE educated, employed part time, married]
Shared infant feeding, which includes a woman’s partner in the feeding process, was a high priority for all of the women and this strongly influenced their infant feeding intentions. Four women had considered expressing breast milk throughout the day to allow their partner to feed their child, while the remaining three women expressed an interest in utilising infant artificial milk to allow other family members to be involved in the infant feeding experience: I think I quite like to maybe do a mixture so that my husband can be involved in the feeding.. I know you can express but it just sounds really really tricky and messy.. I quite like the flexibility of doing both anyway [30 years, TAFE educated, employed part time, married] Factors that influence infant feeding intention A woman’s intention to breast feed is influenced by many factors, including their employment and education level, their own breast feeding experience, and the influence of a woman’s partner, family and friends. All of the participants were breast fed as children, and this was found to positively influence their attitudes towards breast feeding. However this experience was not the main factor to directly impact on their intention to breast feed. Women felt that being breast fed as an infant provided them with a culture where breast feeding was the social norm and it
Barriers to successful breast feeding A number of barriers to successful breast feeding were noted by the participants. The main barrier for all women was their concern about breast feeding in public. Women said they felt that the local community was unsupportive of women who are breast feeding. Women felt embarrassed to breast feed in public and said they would take precautions to not offend other community members (if they did choose to breast feed in public). Women were unaware of the designated public spaces where they are allowed to breast feed their infant, or if there are any regulations regarding breast feeding in public places. The use of breast feeding rooms was considered one possibility, however it was felt that these rooms are lacking in the community, and those that do exist are not hygienic or a desirable environment to feed an infant. Overall, women felt the community could do a lot more to create supportive environments for women who are breast feeding. Specifically, women want more focus on developing ‘breast-feeding friendly’ public and community spaces: I think when I see someone breastfeeding in public I don’t have an issue with it and I think it is good.. whether I would feel
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comfortable well I am not sure at this stage [30 years, TAFE educated, employed part time, married]
Discussion
I haven’t even looked at where you are allowed to do it (breastfeed) or are you technically allowed to do it everywhere? [23 years, year 11 education, unemployed, single]
The purpose of this research was to describe infant feeding intentions of first time pregnant women in urban Melbourne, Australia. One of the limitations of this study was that the experiences described are from a very small group of women, and therefore the findings cannot be generalised across all first time pregnant women (Marshall, 1996). It does, however, contribute to the growing body of qualitative work being conducted around infant feeding and the complexities that surround this issue. The findings from this study highlight the need for additional information and support from health services for first time pregnant women, in particular from midwives at antenatal clinics, about infant feeding options in pregnancy. It is widely known that a woman’s intention to breast feed is strongly related to breastfeeding initiation (Donath et al., 2003; Jarman et al., 2008; Wen et al., 2009; Rempel and Moore, 2012), while international studies have shown that prenatal education and professional support positively influence a woman’s breast-feeding intention (Rosen et al., 2008). A study by Rempel and Moore (2012) highlights the importance of peer breast-feeding support to increase a woman’s breast-feeding intention and duration. Despite previous literature having highlighted the importance of prenatal education and support from health professionals to increase a woman’s breastfeeding initiation and duration (Rosen et al., 2008), it appears that women are yet to receive adequate information and support regarding infant feeding options in the prenatal period. This lack of information and support from health professionals may contribute to the low exclusive breast-feeding rates at 6 months currently seen in Australia. The benefits of breast feeding a child are widely known; however there remains a contradiction between information from the WHO and health professionals who encourage breast feeding, and local government and communities who are not investing money to enable supportive environments for mothers to breast feed outside their homes. Enabling supportive environments is a key approach to promote breast feeding in the community, whereby if women are surrounded by supportive networks, the community could see an increase in the rate and duration of breast feeding. Many of the women in this study said they would not feel comfortable breast feeding in public as there is a lack of privacy, and breast-feeding rooms are said to be unhygienic. This factor alone has the potential to lead women towards using infant artificial milk when outside the home, as opposed to continuing with their breast-feeding endeavour. This ultimately results in a decrease in the rate of exclusive breast feeding currently recommended by the WHO. With the WHO guidelines in mind, it is imperative for local governments to invest money to build public spaces that are culturally safe and private, to see the prevalence of breast-feeding rise across urban Melbourne. To improve the rate of breast feeding in Australia, the factors influencing a woman’s infant feeding intention must be understood. Several factors appear to influence a woman’s infant feeding intention, including her own experience of infant feeding, as well as demographic factors such as age, marital status and education, and this is supported by previous literature (Donath et al., 2003; Haslam et al., 2003; Forster et al., 2006). The most common reason for a woman wanting to breast feed was due to the numerous health benefits of breast milk for their infant. Contrary to other findings (Sheehan et al., 2003) this study found that a woman’s partner strongly influenced her intention to breast feed. Hence, it is imperative to ensure that both a man and a woman are aware from an early stage about the importance of, and the numerous health benefits associated with breast feeding an infant.
Infant feeding information sources The provision of information to women about pregnancy and infant feeding options is essential to ensure women are aware of what is happening with their body and the growth of their foetus. In this study women said they were more likely to seek information about infant feeding options from their friends who are pregnant, or who have young children, rather than from health professionals such as midwives and doctors. Women appreciated anecdotes from friends about their experiences and the encouragement and support friends provided on a day to day basis. Moreover, women valued the real life information and experiences they heard from friends compared to the ‘clinical’ information they received from their midwife or general practitioner. Although it was perceived that health professionals provide women with the most accurate medical information about infant feeding, women were more likely to consult their friends for advice rather than health professionals: Everyone sort of says it’s painful to begin with but.. it sort of gets better.. you sort of have to persist, so it’s good that people are being honest and not just saying yeah it’s great! [30 years, TAFE educated, employed part time, married] I wouldn’t say necessarily that the hospital has been, like my appointments have been that helpful, in that I have only had two so far and today there’ll be another one.. so they are few and far between..They will answer any questions you’ve got, bit I don’t feel overly informed by it [23 years, year 11 education, unemployed, single] Women rely heavily on information from books and the internet as it was perceived to be accurate and more accessible than information from health professionals. Typically, the first time pregnant women would search through internet search engines to find answers to questions they had about pregnancy and infant feeding, as well as to seek out additional support during their pregnancy. For example, one woman was searching for information about healthy eating during pregnancy and found that the internet was the most accessible information source available: ‘a lot of the stuff we’re getting is from.. books, or the internet.. try and find the more reputable sites’ [29 years, university educated, employed part time, married]. Women who were in the third trimester of pregnancy and had attended antenatal classes conducted by midwives felt that the session focused on breast feeding provided them and their partner with a clearer understanding of breast feeding, including problems that may arise and strategies to overcome them. However, women were concerned about the lack of information that was provided to them about infant artificial milk, should they want or need to utilise infant artificial milk at any stage. Three of the women felt that the midwives were not willing to discuss the use of infant artificial milk with them due to their own belief that breast feeding is best: ‘she gave us a bit of information about bottle feeding, but. mainly on breastfeeding’ [27 years, university educated, employed part time, married]. Women said that they were not receiving adequate information about infant feeding options from midwives and doctors and so they had to rely on friends’ anecdotes, books and the internet to inform their infant feeding intentions.
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With an increase in prenatal education classes in Australia, it is likely that the rate of initiation and duration of breast feeding among women will increase. The importance of prenatal education classes is made evident in previous studies (Rosen et al., 2008; Rempel and Moore, 2012), where, with additional support from peers and health professionals, women are more likely to breast feed for longer compared to women who do not receive any pre and postnatal support from friends or health professionals. Women said that information from friends about breast feeding was more valuable than information received from health professionals. This supports conclusions from Rempel and Moore (2012) and Hoddinott and Pill (1999) who found that women with peer breast feeding support had stronger intentions to continue breast feeding at 6 months compared to women who received prenatal advice from nurses at antenatal clinics. In order to see an increase in the rate of exclusive breast feeding not only in Australia, but globally, midwives and health professionals must provide women with adequate evidence based information about infant feeding options to allow women to make informed decisions about their infant feeding intention (Schmied et al., 2008; Raisler, 2011). Midwives must be readily available to ensure women can access the necessary support required to maintain breast feeding. This could be through maternal and child nurse hotlines, focusing on guidelines from the WHO and the Australian Breastfeeding Association. Equally, it is important that women who intend to use infant artificial milk from the outset are supported by health professionals to prevent feelings of exclusion, guilt or inadequacy. Ultimately, it is imperative that women are provided with continual support from midwives and health professionals through the pre and postnatal periods, especially during the first months of life, to see the rate of breast feeding increase.
Conclusion In order to increase women’s knowledge of infant feeding options, a more sustained prenatal programme that focuses on infant feeding within antenatal clinics may be necessary. Evidence based information must be provided to women in a supportive environment, outlining the numerous health benefits of breast feeding for both a mother and her child, as well as providing a supportive network to enhance a woman’s confidence to breast feed. If midwives at antenatal clinics create a supportive network during both the prenatal period and continue into the postnatal period, it is anticipated that a woman’s confidence will be enhanced to endure their breast-feeding intention. This, along with greater community support, should see an increase in the incidence and duration of breast feeding in the outer east region of Melbourne, Australia, resulting in better health outcomes for the future generation of children.
Conflict of interest There is no conflict of interest to report.
Acknowledgements We would like to thank Deakin University for supporting this research; Eastern Health for allowing us to recruit participants from their antenatal clinics; Dr. Cate Burns for her contribution to the research; and of course the participants, for which this research would not be possible without. Thank you.
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Infant feeding intentions among first time pregnant women in urban Melbourne, Australia Elissa York, BHSc (Hons) (Research Assistant), Elizabeth Hoban, BA, MPH, PhD (Senior Lecturer)n Deakin University, 221 Burwood Highway, Burwood, Victoria 3152, Australia
a r t i c l e i n f o
abstract
Article history: Received 10 August 2011 Received in revised form 29 June 2012 Accepted 29 June 2012
Objective: to identify first time pregnant women’s infant feeding intentions for the first 2 years of life. Design: a qualitative phenomenological approach was used, with semi-structured interviews as the primary method of data collection. Setting: two of Eastern Health’s antenatal clinics in the outer east region of Melbourne, Australia. Participants: seven first time pregnant women from an Eastern Health antenatal clinic. Main outcome measure: women’s infant feeding intention for the first 2 years of life. Main findings: all the participants intend to breast feed their infant for around 6 months. Women rely heavily on information about infant feeding options from friends, books and the internet, as the information provided by health professionals was found to be inadequate, acquired late in the pregnancy and difficult to access. Key conclusions: the information women receive from midwives at antenatal appointments and parenting classes about infant feeding options is inadequate, as women are not satisfied with the timing, amount and usefulness of the information they receive. Implications for practice: in order to see an increase in the rate of breast feeding it is imperative to create supportive environments for women to breast feed, and for midwives and health professionals to provide information and continued support for women in both the pre- and postnatal period. Crown Copyright & 2012 Published by Elsevier Ltd. All rights reserved.
Keywords: Breast feeding Pregnancy Feeding intention Education
Introduction Breast feeding is widely acknowledged as the most optimal method of infant feeding as it ensures positive health outcomes, growth and development (Armstrong et al., 2002; Australian Breastfeeding Association, 2005; World Health Organisation, 2010a). For an infant, the obtainment of breast milk provides essential nutrients that act as a protective factor against chronic disease (UNICEF, 2008; Australian Government Department of Health and Ageing, 2010). For a mother, breast feeding reduces the risk of premenopausal breast and ovarian cancer, while assisting a woman return to her pre-pregnancy body shape more quickly (Australian Bureau of Statistics, 2001; National Health and Medical Research Council, 2003; Australian Breastfeeding Association, 2005; Commonwealth of Australia, 2007). The World Health Organisation (WHO) recommend exclusive breast feeding for the first 6 months of life, followed by continued breast feeding and the introduction of nutritious complimentary foods up to the age of 2 years or beyond (World Health Organisation, 2010b, 2011). These recommendations are supported in Australian by the
n
Corresponding author. E-mail address: [email protected] (E. Hoban).
National Health and Medical Research Council (Australian Government Department of Health and Ageing, 2009). In Australia in 2007, according to the Longitudinal Study of Australian Children (LSAC), 92 per cent of infants were breast fed at birth, however the rate of breast feeding was found to decline steadily with age (Australian Institute of Family Studies, 2008; Australian Government Department of Health and Ageing, 2009). At 1 month, 71 per cent of infants were being exclusively breast fed, and at 6 months just 14 per cent of infants were exclusively breast fed (Australian Government Department of Health and Ageing, 2009). At 2 years 5 per cent of infants were receiving any breast milk (Australian Institute of Family Studies, 2008; Australian Government Department of Health and Ageing, 2009). More recent data from the Australian Institute of Health and Wellbeing shows that 96 per cent or babies were initially breast fed, but just 15 per cent were exclusively breast fed for less than 6 months (Australian Government Institute of Health and Wellbeing, 2011). These figures are alarmingly low and far from the recommended infant feeding guidelines. Several factors intertwine and influence a woman’s infant feeding intention. Research shows that older maternal age, coinhabiting with a partner, being well educated and being employed part time positively influence a woman’s decision to breast feed (Donath et al., 2003; Haslam et al., 2003; Forster et al.,
0266-6138/$ - see front matter Crown Copyright & 2012 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2012.06.023
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2006; Chertok et al., 2010). As well, women who have supportive social networks, who have breast-feeding self-efficacy, and who are pregnant for the first time are more likely to intend to breast feed their infant (Lee et al., 2005; Meedya et al., 2010). Furthermore, a strong predictor of intention to breast feed is a woman’s own experience of breast feeding as a child; women who were breast fed themselves are more likely to intend to breast feed their infant (Humphreys et al., 1998; Donath et al., 2003; Mitra et al., 2004; Forster et al., 2006). A woman’s intention to breast feed is a strong predictor of breast-feeding behaviour (Donath et al., 2003; Jarman et al., 2008; Meedya et al., 2010). A British study conducted between April 1991 and December 1992 (n ¼10,548) found that prenatal intention to breast feed positively influenced a woman’s initiation and duration of breast feeding (Donath et al., 2003). Of the women who intended to breast feed for at least 4 months, 96.6 per cent of these women initiated breast feeding after birth (Donath et al., 2003). This is compared to women who intended to bottle feed, where just 3.4 per cent initiated breast feeding (Donath et al., 2003). The strength of the relationship between prenatal intention to breast feed and breast-feeding behaviour in the postnatal period is evident in these findings. Prenatal breast-feeding interventions, including participation in focus group and one-on-one discussions conducted by midwives has been found to effectively prolong breast-feeding duration (Rosen et al., 2008). A blind experimental design study conducted in Western Australia with primiparous women (n¼70) who intended to breast feed found that in the intervention group, where women attended teaching sessions about position and attachment of the baby, there were three times as many women breast feeding at 6 weeks postpartum and fewer women with nipple trauma compared to the non-intervention group (Duffy et al., 1997). A similar study was conducted in America (n ¼194) with women who intended to breast feed. The findings show that 54 per cent of women in the intervention group who received prenatal group or one-on-one breast-feeding education, were exclusively breast feeding at 4 months compared to 6.5 per cent in the control group (Rosen et al., 2008). This type of intervention provides evidence that antenatal education classes during pregnancy that focus on breast feeding has the potential to increase breast-feeding rates and duration. Despite this, prenatal midwifery support is yet to provide women with a sense of selfconfidence in their ability to breast feed their infants (Craig and Dietsch, 2010). Epidemiological studies indicate that women in Australia are not currently meeting the WHO recommendations regarding infant feeding practices. There has been little examination as to why this is the case and how different factors, such as the provision of relevant infant feeding information during pregnancy, and the influence that significant others’ have on women’s breast-feeding intention. To contribute to this gap in information a study was conducted with first time pregnant women living in an outer east region of Melbourne, Australia. The aim of the study was to examine women’s infant feeding intentions for the first 2 years of life. More specifically, the study was designed to understand first time pregnant women’s infant feeding intention, the factors that influence a woman’s infant feeding intention, and the perceived barriers to a woman’s intended infant feeding strategy.
Methods Study design A qualitative phenomenological approach (Liamputtong, 2009) was to examine infant feeding intentions of a small sample (n ¼7)
of first time pregnant women in the outer east region of Melbourne, Australia. Qualitative research, also referred to as social research, is focused on identifying the ‘why’, ‘how’ and ‘what’ questions about human views and behaviours (Neergaard et al., 2009). An imperative aspect of qualitative research is the extent to which in depth knowledge is acquired. In all qualitative research, the researcher not only wants to find out ‘what it is’, but of more importance, ‘explain to me – how, why, what’s the significance?’ (Hesse-Biber and Leavy, 2005). Phenomenology is a methodological theory most often used in qualitative research (Liamputtong, 2009). It is primarily concerned with understanding, describing and interpreting human behaviour in regards to personal experiences (Liamputtong, 2010). Sampling and settings Study participants were recruited from two of Eastern Health’s antenatal clinics in Melbourne using a purposive sampling strategy (Liamputtong, 2009, 2010). As well, participants were recruited using snowball sampling, i.e. one first time pregnant women referred the researcher to other women who met the selection criteria, outlined below (Liamputtong, 2009, 2010). Initial interest for participation in the study was gained through the circulation of a recruitment flier at both antenatal clinics; Box Hill and Yarra Ranges. In addition, the researcher attended each antenatal clinic during busy periods in order to approach women who were waiting for appointments. Women were invited to participate if they met the selection criteria. Women were eligible to participate if they were: pregnant for the first time; in the second or third trimester of pregnancy; and aged between 18 and 45 years. First time pregnant women were recruited to ensure they had no previous experience of infant feeding that would impact on their intention. It was imperative to recruit women who were in the second or third trimester of pregnancy to ensure women had had adequate time to consider infant feeding options; women in the first trimester may not have considered this yet. Women were excluded from the study if they were not pregnant for the first time, if they were in the first trimester of pregnancy, or if they were aged outside the specified age criteria. Data collection The main method of collecting qualitative data was the use of in-depth face-to-face interviews, lasting approximately 1 hr (Liamputtong, 2010). Each interview was conducted on a oneoff basis and used a semi-structured interview guide to ensure that key topic areas were discussed with each woman, yet allowing for flexibility during each interview (Liamputtong, 2009). Taylor (2005) suggests that the aim of an in depth interview is to ‘explore the ‘insider perspective’, to capture, in the participants own words, their thoughts, perceptions, feelings and experiences’ (Taylor, 2005). The interviews were conducted at the antenatal clinic or at a nearby location. Throughout the interviews, the investigator was able to take note of the language, phrases, and tone that each woman used to explain their experience and perceptions of their own infant feeding intention. Each interview was audio-recorded and transcribed verbatim by the first author; this acted as the preliminary stage of data analysis (Liamputtong, 2009). Each participant was allocated a code to maintain participant anonymity. This ensured the data was de-identified and not recognisable. The use of semi-structured interviews was particularly important to allow the investigator to ‘elicit information from prepared questions, but at the same time allow the participants to elaborate on their responses’ (Liamputtong, 2010, p. 47). The use of the
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semi-structured interview guide ensured key topic areas were discussed, yet allowed for flexibility within each interview. A critical element of semi-structured interviews was the use of probes to direct and prompt the participant in order to establish a clear and more in depth understanding of their infant feeding intention (Liamputtong, 2009). Data analysis Thematic data analysis was used to adequately identify common themes that reflected the textual data. It was imperative that the researcher conduct and transcribe interviews to ensure knowledge of the data in order to report accurate and insightful findings. (Howitt and Cramer, 2007; Liamputtong, 2009). The use of thematic analysis allowed themes to be identified and analysed within the data set (Liamputtong, 2009). Preliminary analysis was undertaken by the first author and then by the co-author. Constant comparative analysis was then carried out, and only themes identified through paired consensus were included. Data was coded, and pseudonyms were used to maintain participant anonymity (Liamputtong, 2009). Four major themes were developed during the analysis process and they are the focus of this paper: infant feeding intention; factors that influence infant feeding intention; barriers to successful breast feeding; and infant feeding information sources.
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Table 1 Participant demographics. Characteristics Age (mean)
N¼7 27
Country of birth Australia Other
6 1
Marital status Married Partnered
6 1
Education University TAFE Year 11
4 2 1
Employment Full-time Part-time None
2 4 1
Household annual income o $30,000 $30,000–50,000 $50,000–70,000 $70,000–90,000 $90,000 þ
3 1 2 1 0
Breast fed by own mother Current smoker YES NO
7 0 7
Ethics This study adhered to the ethical standards set out in the National Statement on Ethical Conduct in Human Research (Australian Government, 2007). Ethics approval for this study was granted in June 2010 by both the Eastern Health Research and Ethics Committee (EC00211) and the Deakin University Human Research Ethics Committee (EC00213).
Findings Seven first time pregnant women provided written informed consent and were recruited for the study. All the women were in the second or third trimester of pregnancy, ranging between 13 and 39 weeks, and were aged between 23 and 30 years. Six of the participants were married and one was casually dating the father of her child. Four of the participants had university qualifications, two had TAFE qualifications, and one had completed up to Year 11 at school. Demographic details of the participants are outlined in Table 1. Fig. 1 is a visual representation of the major and minor themes that emerged from data analysis: infant feeding intention, factors that influence infant feeding intention, infant feeding information sources and barriers to successful infant feeding. These will be discussed in detail below. Infant feeding intention All of the participants intended to breast feed their infant and none of the women intended to use infant artificial milk from the outset. Despite this, women were aware that breast feeding would be challenging and they may need to utilise infant artificial milk to maintain infant health. Women said that they seldom considered how long they would exclusively breast feed, if they would use an infant artificial milk, or at what age they would introduce complimentary food into their infant’s diet: I intend on breastfeeding.. as long as it all works.. if everything works out I will breastfeed [27 years, university educated, employed part time, married]
In terms of how long I breast feed.. I think I’ll have to play it by ear, I’m sort of of the philosophy, we’re mammals, you breastfeed because the baby doesn’t have any other way of getting nutrients, once they do have other ways then you have your transition period and then you get them on to solids [30 years, TAFE educated, employed part time, married] The main reasons women gave to support their intention to breast feed include the numerous health benefits associated with breast feeding for both the mother and child, as well as the knowledge that breast feeding is recommended by midwives and the medical profession as the most optimal way to feed an infant. All women felt that feeding an infant with artificial milk is portrayed as second best by health professionals and the media, and for this reason they felt pressure from the community to breast feed their child. Women said they would feel a sense of guilt and failure if they had to use infant artificial milk: It’s sort of like if it doesn’t work out then you can fall back on this, but it’s sort of portrayed as you know if you can you should be breastfeeding [29 years, university educated, employed part time, married] ..it is always very much second besty.you would feel a bit of guilt or failure or something definitely..[23 years, university educated, employed part time, married] If I have difficulties I’m happy to use formula, or if I need to top up, I’m happy to go down that rack if I have to but I would prefer not to if I don’t have to [29 years, university educated, employed full time, married] Few women had considered the introduction of complimentary food into their child’s diet. A common notion was that the introduction of complimentary food would be guided by advice provided to them by doctors and midwives in the postnatal period. Women had more often thought about the types of food they would like to introduce into their child’s diet; however they had not considered the timing of the introduction of solids. The types of foods women planned to introduce into their child’s diet
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Childhood
Partner
Knowledge
Own Experience
Factors that Influence Infant Feeding Intention
Friends
Food
Breastfeeding Infant Feeding Intention
Infant Formula
Complimentary Food Friends
Work and Study
Barriers to Successful Infant Feeding
Pain
Infant Feeding Information Sources
Hospital and Clinic
Male Friends Internet and Books Community Acceptance
Antenatal Class
Fig. 1. Major and minor themes that emerged from data analysis.
included predominately home cooked vegetables and fruit. Home prepared complimentary foods were preferred to commercial baby foods; however women said they would purchase commercial baby foods occasionally for the purpose of convenience:
was highly valued, but overall, attitudes towards breast feeding by a woman’s partner, family and friends were found to be more influential on her intention to breast feed, rather than her own experience of being breast fed as a child:
I think I’d like to do my own at home yeah, I imagine I will buy some out of convenience but more so I would prefer to do it at home [29 years, university educated, employed full time, married]
I have one particular close friend..she’s been a great resource for me.. and because it’s recent as opposed to my mum which is 30 years ago, a lot of the knowledge has changed in that time.. but in my family that’s sort of been the standard I guess (breastfeeding) unless there’s been a problem.. and I think the same in my husbands family [30 years, TAFE educated, employed part time, married]
Shared infant feeding, which includes a woman’s partner in the feeding process, was a high priority for all of the women and this strongly influenced their infant feeding intentions. Four women had considered expressing breast milk throughout the day to allow their partner to feed their child, while the remaining three women expressed an interest in utilising infant artificial milk to allow other family members to be involved in the infant feeding experience: I think I quite like to maybe do a mixture so that my husband can be involved in the feeding.. I know you can express but it just sounds really really tricky and messy.. I quite like the flexibility of doing both anyway [30 years, TAFE educated, employed part time, married] Factors that influence infant feeding intention A woman’s intention to breast feed is influenced by many factors, including their employment and education level, their own breast feeding experience, and the influence of a woman’s partner, family and friends. All of the participants were breast fed as children, and this was found to positively influence their attitudes towards breast feeding. However this experience was not the main factor to directly impact on their intention to breast feed. Women felt that being breast fed as an infant provided them with a culture where breast feeding was the social norm and it
Barriers to successful breast feeding A number of barriers to successful breast feeding were noted by the participants. The main barrier for all women was their concern about breast feeding in public. Women said they felt that the local community was unsupportive of women who are breast feeding. Women felt embarrassed to breast feed in public and said they would take precautions to not offend other community members (if they did choose to breast feed in public). Women were unaware of the designated public spaces where they are allowed to breast feed their infant, or if there are any regulations regarding breast feeding in public places. The use of breast feeding rooms was considered one possibility, however it was felt that these rooms are lacking in the community, and those that do exist are not hygienic or a desirable environment to feed an infant. Overall, women felt the community could do a lot more to create supportive environments for women who are breast feeding. Specifically, women want more focus on developing ‘breast-feeding friendly’ public and community spaces: I think when I see someone breastfeeding in public I don’t have an issue with it and I think it is good.. whether I would feel
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comfortable well I am not sure at this stage [30 years, TAFE educated, employed part time, married]
Discussion
I haven’t even looked at where you are allowed to do it (breastfeed) or are you technically allowed to do it everywhere? [23 years, year 11 education, unemployed, single]
The purpose of this research was to describe infant feeding intentions of first time pregnant women in urban Melbourne, Australia. One of the limitations of this study was that the experiences described are from a very small group of women, and therefore the findings cannot be generalised across all first time pregnant women (Marshall, 1996). It does, however, contribute to the growing body of qualitative work being conducted around infant feeding and the complexities that surround this issue. The findings from this study highlight the need for additional information and support from health services for first time pregnant women, in particular from midwives at antenatal clinics, about infant feeding options in pregnancy. It is widely known that a woman’s intention to breast feed is strongly related to breastfeeding initiation (Donath et al., 2003; Jarman et al., 2008; Wen et al., 2009; Rempel and Moore, 2012), while international studies have shown that prenatal education and professional support positively influence a woman’s breast-feeding intention (Rosen et al., 2008). A study by Rempel and Moore (2012) highlights the importance of peer breast-feeding support to increase a woman’s breast-feeding intention and duration. Despite previous literature having highlighted the importance of prenatal education and support from health professionals to increase a woman’s breastfeeding initiation and duration (Rosen et al., 2008), it appears that women are yet to receive adequate information and support regarding infant feeding options in the prenatal period. This lack of information and support from health professionals may contribute to the low exclusive breast-feeding rates at 6 months currently seen in Australia. The benefits of breast feeding a child are widely known; however there remains a contradiction between information from the WHO and health professionals who encourage breast feeding, and local government and communities who are not investing money to enable supportive environments for mothers to breast feed outside their homes. Enabling supportive environments is a key approach to promote breast feeding in the community, whereby if women are surrounded by supportive networks, the community could see an increase in the rate and duration of breast feeding. Many of the women in this study said they would not feel comfortable breast feeding in public as there is a lack of privacy, and breast-feeding rooms are said to be unhygienic. This factor alone has the potential to lead women towards using infant artificial milk when outside the home, as opposed to continuing with their breast-feeding endeavour. This ultimately results in a decrease in the rate of exclusive breast feeding currently recommended by the WHO. With the WHO guidelines in mind, it is imperative for local governments to invest money to build public spaces that are culturally safe and private, to see the prevalence of breast-feeding rise across urban Melbourne. To improve the rate of breast feeding in Australia, the factors influencing a woman’s infant feeding intention must be understood. Several factors appear to influence a woman’s infant feeding intention, including her own experience of infant feeding, as well as demographic factors such as age, marital status and education, and this is supported by previous literature (Donath et al., 2003; Haslam et al., 2003; Forster et al., 2006). The most common reason for a woman wanting to breast feed was due to the numerous health benefits of breast milk for their infant. Contrary to other findings (Sheehan et al., 2003) this study found that a woman’s partner strongly influenced her intention to breast feed. Hence, it is imperative to ensure that both a man and a woman are aware from an early stage about the importance of, and the numerous health benefits associated with breast feeding an infant.
Infant feeding information sources The provision of information to women about pregnancy and infant feeding options is essential to ensure women are aware of what is happening with their body and the growth of their foetus. In this study women said they were more likely to seek information about infant feeding options from their friends who are pregnant, or who have young children, rather than from health professionals such as midwives and doctors. Women appreciated anecdotes from friends about their experiences and the encouragement and support friends provided on a day to day basis. Moreover, women valued the real life information and experiences they heard from friends compared to the ‘clinical’ information they received from their midwife or general practitioner. Although it was perceived that health professionals provide women with the most accurate medical information about infant feeding, women were more likely to consult their friends for advice rather than health professionals: Everyone sort of says it’s painful to begin with but.. it sort of gets better.. you sort of have to persist, so it’s good that people are being honest and not just saying yeah it’s great! [30 years, TAFE educated, employed part time, married] I wouldn’t say necessarily that the hospital has been, like my appointments have been that helpful, in that I have only had two so far and today there’ll be another one.. so they are few and far between..They will answer any questions you’ve got, bit I don’t feel overly informed by it [23 years, year 11 education, unemployed, single] Women rely heavily on information from books and the internet as it was perceived to be accurate and more accessible than information from health professionals. Typically, the first time pregnant women would search through internet search engines to find answers to questions they had about pregnancy and infant feeding, as well as to seek out additional support during their pregnancy. For example, one woman was searching for information about healthy eating during pregnancy and found that the internet was the most accessible information source available: ‘a lot of the stuff we’re getting is from.. books, or the internet.. try and find the more reputable sites’ [29 years, university educated, employed part time, married]. Women who were in the third trimester of pregnancy and had attended antenatal classes conducted by midwives felt that the session focused on breast feeding provided them and their partner with a clearer understanding of breast feeding, including problems that may arise and strategies to overcome them. However, women were concerned about the lack of information that was provided to them about infant artificial milk, should they want or need to utilise infant artificial milk at any stage. Three of the women felt that the midwives were not willing to discuss the use of infant artificial milk with them due to their own belief that breast feeding is best: ‘she gave us a bit of information about bottle feeding, but. mainly on breastfeeding’ [27 years, university educated, employed part time, married]. Women said that they were not receiving adequate information about infant feeding options from midwives and doctors and so they had to rely on friends’ anecdotes, books and the internet to inform their infant feeding intentions.
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With an increase in prenatal education classes in Australia, it is likely that the rate of initiation and duration of breast feeding among women will increase. The importance of prenatal education classes is made evident in previous studies (Rosen et al., 2008; Rempel and Moore, 2012), where, with additional support from peers and health professionals, women are more likely to breast feed for longer compared to women who do not receive any pre and postnatal support from friends or health professionals. Women said that information from friends about breast feeding was more valuable than information received from health professionals. This supports conclusions from Rempel and Moore (2012) and Hoddinott and Pill (1999) who found that women with peer breast feeding support had stronger intentions to continue breast feeding at 6 months compared to women who received prenatal advice from nurses at antenatal clinics. In order to see an increase in the rate of exclusive breast feeding not only in Australia, but globally, midwives and health professionals must provide women with adequate evidence based information about infant feeding options to allow women to make informed decisions about their infant feeding intention (Schmied et al., 2008; Raisler, 2011). Midwives must be readily available to ensure women can access the necessary support required to maintain breast feeding. This could be through maternal and child nurse hotlines, focusing on guidelines from the WHO and the Australian Breastfeeding Association. Equally, it is important that women who intend to use infant artificial milk from the outset are supported by health professionals to prevent feelings of exclusion, guilt or inadequacy. Ultimately, it is imperative that women are provided with continual support from midwives and health professionals through the pre and postnatal periods, especially during the first months of life, to see the rate of breast feeding increase.
Conclusion In order to increase women’s knowledge of infant feeding options, a more sustained prenatal programme that focuses on infant feeding within antenatal clinics may be necessary. Evidence based information must be provided to women in a supportive environment, outlining the numerous health benefits of breast feeding for both a mother and her child, as well as providing a supportive network to enhance a woman’s confidence to breast feed. If midwives at antenatal clinics create a supportive network during both the prenatal period and continue into the postnatal period, it is anticipated that a woman’s confidence will be enhanced to endure their breast-feeding intention. This, along with greater community support, should see an increase in the incidence and duration of breast feeding in the outer east region of Melbourne, Australia, resulting in better health outcomes for the future generation of children.
Conflict of interest There is no conflict of interest to report.
Acknowledgements We would like to thank Deakin University for supporting this research; Eastern Health for allowing us to recruit participants from their antenatal clinics; Dr. Cate Burns for her contribution to the research; and of course the participants, for which this research would not be possible without. Thank you.
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