FACTORS THAT INFLUENCE BREASTFEEDING

Factors that Influence Mothers to Breastfeed

Arica C. Hardgrove, Eric W. Harris, Sarah A. Perry, Emily J. Schrecengost, and Jacob A.

Velasco

04/06/2016

NURS 3749: Nursing Research

Dr. Valerie ODell

Factors that Influence Breastfeeding 1

Abstract

The purpose of this research was to identify the factors that influence a mothers decision to

breastfeed. Each factor can have a positive or negative effect on a mothers decision to

breastfeed. Specifically, our aim was to evaluate previous studies that address the factors of:

knowledge barriers, maternal health, the role of the health care professional, obesity,

intergenerational influence, interpersonal support, sexuality of the breast, and socioeconomic

status. The following research was drawn from 24 sources and a combination of both

quantitative and qualitative studies. It was found that the numerous health benefits of

breastfeeding play a role in its initiation, but knowledge alone is not enough to show a stable

increase in rates of breastfeeding. It was suggested that a more multi-faceted approach,

stemming from the above topics, is needed to help increase these rates.
Factors that Influence Breastfeeding 2

Factors that Influence Mothers to Breastfeed

Motherhood involves making a multitude of decisions. One important choice a mother

makes may have a huge impact on the infants entire life breastfeeding or formula feeding? In

defiance of wide-spread recognition, due in part to numerous studies, of the positive outcomes of

breastfeeding, rates continue to hit below the goal set by Healthy People 2020. Healthcare

providers play a crucial part in a mothers decisions, whether it be throughout the pregnancy, in

the hospital during labor, and even after the baby is born. Teaching, counseling, and supporting

the mothers about breastfeeding may help increase its occurrence. It is important for healthcare

providers, such as doctors and nurses, to know the many reasons influencing a mothers choice

to breastfeed or formula feed; thus, the following research question was examined: What factors

influence a mother to breastfeed?

Literature Review

Introduction

To investigate this topic in nursing, literature was gathered using online research

databases such as MEDLINE (PubMed), CINHAL Plus, and EBSCOhost. Twenty-four (24)

sources were analyzed to gather information on the factors that influence women to breastfeed.

Health and knowledge, the role of the health care professional, obesity, intergenerational

influence, interpersonal support, sexuality of the breast, and socioeconomic status will be

discussed.

Health & Knowledge

Factors that Influence Breastfeeding 3

Among the many factors a woman parses through when deciding about breastfeeding,

both maternal and infant health play a key role. Many studies and much public research

highlight the positive health benefits of breastfeeding (Dunn, Kalich, Henning, and Fedrizzi,

2015). The Surgeon General of the United States made note of the many benefits breastfeeding

imparts to the infant: protection from gastrointestinal illnesses, ear infections, and respiratory

diseases round the top of the list. Breastfeeding has also been shown to reduce the risk of

childhood obesity and Sudden Infant Death Syndrome (SIDS). The health benefits of

breastfeeding not only work in favor of the child, but also the mother; women who breastfeed

have a lower occurrence of breast and ovarian cancers (United States Department of Health and

Human Services [USDHHS], 2011).

Another significant factor influencing the breastfeeding decision is knowledge. A

combination of familial/peer influence, school education, and cultural norms can teach women

about breastfeeding, its benefits, and also what difficulties may lay ahead. Despite ease of access

women have to this plethora of knowledge about breastfeeding and the maternal/infant health

benefits, there is a clearly established deficit in breastfeeding rates; this has been found,

especially, of women from lower socioeconomic brackets and some minority groups (Dunn,

Kalich, Henning, and Fedrizzi, 2015). It is identified that the breastfeeding rates in the United

States are lower than the recommended standard by the United States Department of Health and

Human Services (USDHHS,2011). Healthy People 2020 has outlined the objectives of 82% of

infants being breastfed in total, 61% of infants breastfed at 6 months, and 34% at one year. The

rates in 2006 were: 74% breastfed in total, 43.5% at 6 months, and 22.7% at one year. It is

glaringly clear that the expectations and standards of breastfeeding are rising (United States
Factors that Influence Breastfeeding 4

Department of Health and Human Services [USDHHS], 2010). While there is documented

evidence that breastfeeding heightens maternal and infant health as mentioned above, the rates of

breastfeeding remain lower than the ideal standard (Dunn, Kalich, Henning, and Fedrizzi, 2015).

Different interventions have been tested with the common goal of a positive influence on

breastfeeding rates. In an experiment conducted by Kellams et al. (2016), an educational

intervention was tested. In this experiment a low-cost, educational breastfeeding video was

shown to women during their third trimester of pregnancy. The results of this randomized,

controlled trial showed that the intervention did not influence breastfeeding positively or

negatively. Possible reasons for the lack of impact could be the timing of the intervention, as

the study points out that many women make their decision to breastfeed much earlier in their

pregnancy, if not before they actually become pregnant. The study suggests that one educational

video alone is not enough to increase breastfeeding rates, but rather a collaborative environment

of supportive health care staff, family members, and cultural/social support could make

educational materials regarding breastfeeding much more effective (Kellams et al., 2016).

Role of the Health Care Professional

The Surgeon General of the United States documented several issues that women face

when they try to breastfeed. One of these challenges is a lack of updated educational material, as

well as insufficient instruction from health care professionals. Also, some hospitals may not be

as accommodating as possible to facilitate the initiation of breastfeeding (USDHHS, 2011).

Radzyminski and Callister (2015) conducted a study to find out the attitudes of health-care

providers in terms of breastfeeding and the promotion of it. All of the health care professionals

discussed the positive benefits of breastfeeding during interviews in this qualitative study. Also,
Factors that Influence Breastfeeding 5

all of the participants felt that breastfeeding should be initiated as soon as possible after birth.

Despite this information, the research showed a gap between the knowledge of breastfeeding

benefits and the actual promotion of it in clinical practice. Also, the study noted a deficiency in

assessment and therapeutic skills that help facilitate breastfeeding. Several of the participants in

the study felt that the approach to feeding was up to the mother, and that once they returned

home, the success of the continuation of breastfeeding depended, mostly, on a supportive

environment. The research concludes that to increase promotion and support of breastfeeding,

the attitudes of health-care professionals must change; increased confidence can change the

clinical environment into a more effective one (Radzyminski & Callister, 2015).

A different study taking place in the United Kingdom sought to identify themes regarding

the promotion of breastfeeding among healthcare professionals through interviewing of those

working with new mothers. A common theme discussed was the perceived powerlessness of the

health care professional. Many participants felt that family and the perceived norms of culture

and society through media impacted women and their ideas about breastfeeding more than the

influence of those working in health care. In addition, some professionals felt that

over-promoting breastfeeding can make mothers feel incompetent if they experience difficulties,

further discouraging them from breastfeeding altogether. The study indicated that professionals

downplay their influence in a mothers decision to breastfeed, and that they education to be

better than promotion (Marks & OConnor, 2015).

Maternal obesity

According to the World Health Organization (WHO), obesity can be defined as someone

with a BMI greater than 30 (WHO 2011). BMI is calculated by dividing a persons weight (in
Factors that Influence Breastfeeding 6

kilograms) by his or her height (in meters) in or to detect abnormal fat buildup that could

potentially impose a problem to ones health. Not only is obesity it a health concern on its own,

but it may also decrease the intention, initiation and duration of breastfeeding. Maternal obesity

could cause reduced milk supply and delayed onset of milk secretion as well (Turcksin, Bel,

Galjaard, Devlieger 2014).

Turcksin et. al. conducted a systematic review involving 19 articles that explore the

relationship of maternal obesity and the intention, initiation, intensity, and duration of

breastfeeding as well as milk supply (Turcksin et al., 2014). Two of these studies focused on the

intention of breastfeeding. Hilsons study (as cited in Turcksin et al., 2014), found obese women

plan to breastfeed a shorter amount of time (6.9 months) than women of normal weight (9.3

months). Another study infers that a substantially lower amount of obese women that plan to

breastfeed as compared to women of normal weight (Turcksin et al., 2014).

A different portion of Turcksins review focused on the initiation of breastfeeding.

There were 15 of the 16 studied about breastfeeding initiation included in this review that

demonstrate decreased breastfeeding initiation rates among obese women, compared with their

normal weight counterparts (Turcksin et al., 2014, p. 178). The duration of breastfeeding is also

shown to be shortened in obese women when compared to the duration of breastfeeding in

women of a healthy weight. This is also true for exclusive breastfeeding duration (Turcksin et al.,

2014). Guelinckx et al. (2011) find that obese women give insufficient milk as a reason to cease

breastfeeding more frequently than other women (24% vs. 13%, P=0.041) (Turcksin et al., 2014,

p. 180).
Factors that Influence Breastfeeding 7

The results of Turcksins systematic review declare that maternal obesity correlates to

less intention of breastfeeding intention as well as a lower likelihood of initiation and

continuation of breastfeeding. The review also indicates that compared to women of normal

weight, women who are obese have a lower milk transfer. The journal brings attention to

possible reasons for the negative relationship of breastfeeding and obese women. As

comprehensively reviewed by Amir and Donath (2007), the reasons why overweight and obese

women are less likely to breastfeed include anatomical, sociocultural, but also medical and

psychological factors (Turcksin et al., 2014 p. 180). Although many issues that influence

breastfeeding are reported by all mothers, obese mothers more commonly report a perceived lack

of milk supply as well as feeling uncomfortable with public breastfeeding than non-overweight

mothers. (Visram et al., 2013). Regardless of possible explanations for the results, it is important

to note that maternal obesity may have a negative effect on breastfeeding; another analysis (as

cited in Visram et al., 2013, p. 613), found that 64% of women of normal weight initiated

breastfeeding, as compared to only 48% of obese women.

Intergenerational Continuity

Studies were conducted to investigate the relationship between breastfeeding in one

generation and breastfeeding in the second generation, hoping to explain whether being breastfed

as a child influences ones plan, initiation, and extent of breastfeeding as an adult. In a

systematic review done by Laura Di Manno, Jacqui A. Macdonald, and Tess Knight, 15 eligible

studies were revised (2015). Six of these studies report that being breastfed as an infant is

correlated to higher intent to breastfeed in the future (Di Manno et al, 2015). Four studies

reviewed included male participants as well as female participants, and these studies showed a
Factors that Influence Breastfeeding 8

positive correlation between males who were breastfed and their intent to provide support and

encouragement of breastfeeding to their partner (Di Manno et al, 2015). Five studies focused on

the initiation of breastfeeding; of these, four state that being breastfed as an infant was a

substantial positive predictor of initiation of breastfeeding (Di Manno et al, 2015). In the

reviewed studies, breastfeeding initiation was consistently found to be more likely to occur if the

mother has been breastfed. This finding indicates an intergenerational influence, even after

accounting for variables that commonly confound breastfeeding behavior such as maternal

smoking, maternal education, and maternal age (Di Manno et al, 2015, p. 13). Marjorie Atchan,

Maralyn Foureur, and Deborah Davis (2011), claim in their literature review that knowing they

were breastfed as an infant or having a friend who breastfed not only produces a positive attitude

regarding breastfeeding, but also boosted confidence and may even be more important than

factors commonly associated with breastfeeding, such as age and education.

When addressing how ones breastfeeding history influenced their own breastfeeding

decisions, studies support that having been breastfed significantly impacts the intention,

initiation, duration, and exclusivity of breastfeeding; [h]owever, no study reviewed explored

mechanisms that might account for this association and causality could not be established given

the study designs employed (Di Manno et al, 2015, p. 14). These findings are important in

acknowledging that a womans breastfeeding choices may be related her or her partners history

with breastfeeding. Understanding a couples own history of having been breastfed could allow

for targeted promotion of breastfeeding information and support in the early gestational period

(Di Manno et al, 2015, p. 13).

Factors that Influence Breastfeeding 9

Support

As detailed previously, many key factors influence a mothers decision to breastfeed,

especially including familial support along with encouragement from peers. Accurate and

consistent information is also important in influencing breastfeeding. In an article in Springer

Science and Business, one obstetrician stated: I think new moms are particularly vulnerable to

the people with whom they live[. That] persons support or lack of support, knowledge or lack

of knowledge. (Gazmararian, Dalmida, Merino, Blake, Thompson & Gaydos, 2013, p.844).

As mentioned earlier, if the spouse and the mother were breastfed, theres a higher

chance they may breastfeed their children. Spouse support also plays a strong role in the decision

to breastfeed- one study mentions that for the father to play a supportive role, they must be:

knowledgeable about breastfeeding, have a positive attitude towards breastfeeding, be an active

participant in the decision-making process, and provide practical and emotional support

(Sherriff, Panton, & Hall, 2014). It is also stated that the fathers empathy towards the

breastfeeding mother is crucial in success. Attention should be brought not only to the

breastfeeding mother, but also the father and how they can be more active in caring for the new

child. Another study showed that the mothers expressed concerns about the father's ability to

care for the infant (Gazmararian et al., 2013). In relation to support from the spouse, there are

also cases in which no support from the spouse or intimate partner exists, and violence is present.

It can be noted that intimate partner violence is prevalent among new mothers and has a negative

effect on their health both physically and emotionally; surprisingly, women who experience

intimate partner violence are just as likely to breastfeed as the broader population of women

(James, Taft, Amir, & Aguis, 2014).

Factors that Influence Breastfeeding
10
Sexuality of the Breast

Among the many factors and influences on the decision to breastfeed, Isabell B.

Purdy (2010) notes that the objectification of the breast as an erotic, sexual object in our

society, a related fear of breast disfigurement, negative community reaction to breast feeding as

indecent exposure is highly prevalent (p.365). The breast is viewed as a highly sexual symbol

in American culture and this most certainly plays a role in the mothers decision to breastfeed at

all, as well as how long they continue to breastfeed should that decision be made. One article

mentions that woman expressed repeated feelings of social isolation and vulnerability along with

unsettling feelings of turning men on while feeding in public (Hurst, 2013). Teresa Smith

(2015) comments on the subject stating Controversy surrounding breastfeeding in public

underscores the high level of discomfort that exists regarding the use of the breast for infant

feeding. (p.54). Smith (2015) proposes the Permission Theory of Breastfeeding: [t]his theory

suggests that since breasts are seen to exist primarily for the pleasure of the womans partner,

they are viewed as his property. (p.54). Her research indicates that women with disapproving

partners were highly unlikely to breastfeed because they lacked permission from the spouse.

One factor that may help women feel more comfortable with breastfeeding, especially in public,

is that the National Conference of State Legislature now protects a woman's right to breastfeed in

most public spaces in the United States (Hurst, 2013, p.23).

Socioeconomic Status

According to Campbell, Wan, Speck, and Hartig (2014), breastfeeding rates in low

income brackets, as well as women with less than a high school education are well below the

goals set by Healthy People 2020. Women of lower socioeconomic status are commonly
Factors that Influence Breastfeeding
11
referred to Women, Infants, and Children, or WIC, which helps impoverished mothers care for

themselves and their infants and children (Conner, McEachan, Jackson, McMillan, Woolridge, &

Lawton, 2013). Metallinos-Katsaras, Brown, & Colchamiro (2014) state that WIC actually has a

positive effect on breastfeeding rates; a greater exposure to WIC services correlated to a higher

likelihood of breastfeeding, as well as a longer duration of breastfeeding. Campbell et. al. (2014)

found that even if a mother had a child that she did not breastfeed previously, when having

another child and receiving WIC peer counseling, the mother was more likely to breastfeed the

new infant than those that did not receive WIC peer counseling. WIC does provide free formula

to mothers in the program; however, the amount of formula the they give to mothers is not

sufficient enough for the infant's needs, requiring them to purchase more formula, which they

often cannot afford due to their socioeconomic status. This forces some mothers to breastfeed out

of necessity rather than out of choice (Fornasaro-Donahue, Tovar, Siberia, & Greene, 2014).

WIC also supports breastfeeding by providing access to obstetricians, midwives, and lactation

consultants that provide support and education, all of which positively contribute to

breastfeeding success, causing an increased rate in breastfeeding (Dunn, Kalich, Henning,

Fedrizzi, 2014). This support is necessary- disadvantaged and low socioeconomic mothers felt

that the benefits of breastfeeding were not often a big enough positive to outweigh the perceived

barriers to breastfeeding (MacGregor & Hughes, 2010). On the other hand, according to Ma, Liu,

and Smith (2014), income eligible non-WIC participants were more likely to breastfeed than

WIC participants because they were not receiving free formula and could not afford to buy

formula on their own.

Factors that Influence Breastfeeding
12
Even with all the assistance WIC provides, disadvantaged women and women from low

income brackets still have a much lower rate of breastfeeding (Campbell et al., 2014). Conner et

al. (2014) found that as the mothers socioeconomic status increased, the incidence of

breastfeeding also increased. Teenage mothers are also perceived as disadvantaged women and

women from low income brackets, and they tend they follow the same pattern. MacGregor and

Hughes (2014) found that teenage mothers are fifty percent less likely to breastfeed than older

mothers. The same study also infers that women with lower levels of education are generally

from lower income brackets, and as such are less likely to breastfeed compared to women with

higher levels of education (MacGregor & Hughes, 2014). Conner et al. (2014) found that the

idea that higher levels of deprivation (i.e., lower socioeconomic status) may impede attempts to

translate healthy intentions into healthy actions. Healthy intentions included breast feeding,

therefore, even if the mother wanted to breastfeed there are barriers to breastfeeding that women

from lower socioeconomic classes have barriers to breastfeeding that women from higher

socioeconomic classes do not have (Conner et al., 2014)

Conclusion

Throughout this literature review, we sought to discuss and highlight the many factors

influencing a mothers decision to breastfeed. Most commonly, general knowledge is a hurdle-

yet, numerous perceived and physical barriers also exist that influence the decision. As noted,

the health of the mother (including obesity) as well as infant health play a significant role in the

quandry. Included in this is the role of the healthcare provider, whose proper guidance,

education, and encouragement can positively influence the rate of breastfeeding. Emotional

support in the forms of intergenerational guidance, interpersonal, and spousal support also can
Factors that Influence Breastfeeding
13
sway the choice both positively and negatively. Most physically, the hyper-sexualization of the

breast largely contributes a negative connotation to breastfeeding. Also, from a monetary

standpoint, we saw that low economic status translated to a lower rate of breastfeeding; however,

mothers in the same socio-economic status that used WIC services showed a positive correlation

to breastfeeding.
Factors that Influence Breastfeeding
14
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