Abstract
Abstract
Background:
Social networks and subjective norms (individuals' perceptions of what other people think) can be influential in decision-making. Although there are data about the importance of support in initiation and duration of breastfeeding, no studies have explored the influence of women's social networks and the norms within those networks on breastfeeding.
Research Aim:
To investigate, through qualitative methods, the influence of mothers' social networks and subjective norms, both within and outside of her network, with regard to breastfeeding practices.
Materials and Methods:
Twenty-eight mothers participated in focus groups or individual interviews. Probing questions concerning breastfeeding intent, initiation, continuation, and support with regard to social networks and subjective norms were asked. Themes were developed in an iterative manner from coded data. Matrix coding queries assessed patterns in the data and compared quotes based on the respondents' race and social network type.
Results:
General themes that emerged were the importance of breastfeeding experience within one's social network, the influence of the infant's father, handling disagreement within one's network, and the effects of social norms that exist outside of one's network. Mothers described support for breastfeeding from network members as especially important when breastfeeding was not the norm within the network. There were no differences in themes by race or social network type.
Conclusion:
Breastfeeding behavior is influenced by a mother's social network, regardless of her race or social network type. Even when breastfeeding is not normative within one's social network, by relying on one network member to support them, mothers may be able to resist the opposing norms of their social network. Since breastfeeding is known to be beneficial to infants and mothers, education or interventions to improve breastfeeding rates may be more effective if they include individual network members who can provide strong support to new mothers.
Introduction
Breast milk is well established as the best source of infant nutrition with benefits, including associations with increased immunity, higher cognition, and a lower risk of infant mortality, including sudden infant death syndrome (SIDS). 1 The protective effect of breastfeeding against SIDS increases with duration and exclusivity of breast milk feeding.2–4 Recent data from the Centers for Disease Control and Prevention (CDC) indicate that in 2013, 81.1% of mothers initiated breastfeeding, 51.8% continued breastfeeding for 6 months, and 30.7% continued throughout the 1st year. The CDC also reports that 60% of mothers stop breastfeeding sooner than they want to wean. 5 Barriers to breastfeeding include the mode of delivery, 6 return to work,7,8 and lack of prenatal breastfeeding education. 9
Social networks describe the structure of one's social interactions and personal relationships. 10 Individual's social network may comprise immediate and extended family members, friends, coworkers, and/or health professionals. These individuals can strongly influence one's decisions regarding breastfeeding. A study of first-time African American (AA) mothers showed that support from family members, friends, public health nurses, and church members impacted the decision to initiate, continue, or stop breastfeeding. 11 Thus, when trying to improve breastfeeding rates, it is important to understand these social networks.
We have found that there are two types of social networks for mothers of young infants—exclusive networks and expansive networks. Exclusive networks are more restricted and largely comprised kin, whereas expansive networks include friends, colleagues, and others in addition to kin. 12
Social norms are the behaviors that members within a group (i.e., the social network) perceive to be normal or acceptable.13,14 Although the norms within a social network are often established by the practices and beliefs of the majority of individuals in the network, they can also be established by the stated opinions of one or two more influential members, whose judgment dictates what others believe is acceptable. Individual network members often adhere to these norms to avoid social stigma.
Although breastfeeding is a personal experience, the decisions to initiate and continue breastfeeding are guided by one's norms, 13 and influenced by the explicit or implicit opinions of others in one's social network regarding the pros and cons of breastfeeding and the optimal duration of breastfeeding. 15 The influence of these norms varies by individual. For instance, a first-time mother may be more influenced by a norm than a multiparous mother who has previous experience with either breast or formula feeding. 16
Given the importance of breastfeeding on infant and maternal health, we conducted a qualitative study of AA and Caucasian mothers to better understand mothers' perceptions of and reactions to the norms pertaining to breastfeeding, both within and outside of their social networks, and how these influence breastfeeding decisions.
Materials and Methods
Design
We analyzed qualitative data from AA and Caucasian mothers regarding their social networks, breastfeeding norms inside and outside their social networks, and the influence of these networks and norms on their decisions regarding breastfeeding initiation, continuation, and cessation. We used both focus group interviews and individual in-depth semistructured interviews to accommodate more mothers' schedules (mothers who could not participate in focus groups could participate in individual interviews). In addition, the two interview formats can be used to obtain a wide range of possible responses. Participants who might be reticent in one-on-one interviews may be more likely to participate in a group of people with similar backgrounds 17 ; however, participants may be more likely to discuss socially sensitive topics in individual interviews. 18 This study was approved by the institutional review boards of Children's National Medical Center and the University of Virginia.
Sample and setting
Custodial mothers of healthy term infants living in the metropolitan Washington, DC, area were recruited from a birth hospital and through respondent-driven sampling to participate in a larger quantitative survey about their personal social networks if they were English-speaking, AA or Caucasian, >18 years of age, and their infants were full term (>36 weeks gestation) and did not have medical conditions requiring subspecialty care. The goal was to recruit two-thirds AA and one-third Caucasian women to approximate the population of Washington, DC, as a whole. Each mother signed written informed consent upon enrollment. From this sample, we selected a subsample 19 whom we predicted, based on their child's age, their race and their parity, would have a broad range of attitudes and opinions, to participate in focus groups or individual interviews. Each qualitative interview participant signed a separate written informed consent before the interview.
Data collection
All focus groups and individual interviews were conducted between July 2016 and January 2018. Focus groups were stratified by race and parity (primiparous or multiparous), as homogeneity of group participants has been shown to increase the comfort level of participants, making them more willing to share their thoughts and opinions. 20 All authors worked together to develop interview questions. The same interview guide was used for both interview formats, and questions were modified iteratively as qualitative data analysis proceeded. All interviews were conducted by trained facilitators (R.O., A.M.). In both interview formats participants were first asked broad open-ended questions (e.g., Who gave you advice about how to feed your baby?), which were then followed up by more specific probing questions (e.g., Did you feel pressured to breastfeed or formula feed?) to clarify responses. Focus group interviews averaged 2 hours in duration, and individual interviews averaged 90 minutes in duration. Each focus group and individual interview participant received a $75 gift card for their time.
Data analysis
All qualitative interviews were video- and audio-recorded and transcribed by a HIPAA-compliant transcription company. To maximize accuracy and eliminate bias from the transcription process we used a multistep process to review the interview transcripts. After initial transcription, the video- and audio-recordings and transcript of each interview were simultaneously reviewed by an author (R.O.) to ensure accuracy. All discrepancies in the transcription were reviewed by additional authors who listened to the recordings to reach consensus.
Once finalized, we analyzed transcripts line by line, using standard qualitative analytic techniques. Qualitative analysis software (NVivo 11 plus 21 ) was used to organize, sort, and code the data (quotations). We developed and revised themes in an iterative manner, as patterns within data became more apparent. 22 Authors met on a regular basis to review the emerging themes and patterns and to come to consensus on the major themes.
The two interview formats (individual and focus group interviews) were initially analyzed separately, and then compared to ensure thematic consensus of both formats. Matrix coding queries were also conducted to assess patterns in the data and compare quotes based on the respondents' race and social network type. We used concurrent triangulation, or the use of multiple sources for verification of findings, 23 of the focus group interviews and the individual interviews to corroborate findings. 24 In addition, we confirmed findings by presenting to physicians and maternal and child health care professionals for peer review and feedback.
Results
We conducted eight focus groups (median 3.5 participants, range 2–6 participants) and two individual interviews with 28 mothers, and reached thematic saturation. Participant demographics are described in Table 1 and were similar to the demographics of the larger study sample. At the time of the interview, the mean maternal age was 30.4 years (range 20–44 years), 71.4% of the mothers were AA, and more than half of the mothers were primiparous. More than one-third (39.3%) of mothers reported exclusive breastfeeding, whereas 21.4% reported partial breastfeeding. Social network types were characterized as exclusive for 18 women, and expansive for 10 women.
Characteristics of Participants (n = 28)
Central themes
The central themes that emerged regarding social networks, social norms, and breastfeeding were (1) importance of breastfeeding experience within one's social network, (2) influence of infant's father on breastfeeding, (3) handling disagreement within one's network regarding breastfeeding norms, and (4) effect of social norms that exist outside of one's network. Because a matrix coding query to assess any differences in themes by race or social network found that themes were consistent in all interviews, we did not stratify results further. These themes, with illustrative quotes (Q), are discussed as follows. Information about the speaker's race, social network type, and breastfeeding status are noted for each quote.
Importance of breastfeeding experience within one's social network
Mothers experienced varying levels of support from their social networks (Table 2). Many mothers said they wanted to breastfeed because it was normative (e.g., everyone had breastfed) in their social network (Q1, Q2) and they felt network members were supportive of and encouraged breastfeeding. They often pointed to the baby's grandmother, even if she herself had not breastfed (Q3), or friends (Q4, Q5) who had experience raising their own children, as the most important sources of support.
Importance of Breastfeeding Experience Within One's Network
AA, African American.
The degree of social network support mothers felt when they experienced difficulty breastfeeding varied widely and was often dependent on the prior breastfeeding experience of both individual members and the network as a whole. Breastfeeding mothers reported reaching out to network members when they were struggling with breastfeeding. In networks supportive of breastfeeding, women were often referred to network members with additional or more recent experience for help in solving problems (Q6), even if those women were more peripheral in the network.
Some mothers described different supports from network members who had breastfed their children than from those who had not, with network members who had formula-fed believing that breastfeeding was not important (Q7). Some women in networks, where breastfeeding was not normative, were able to overcome the negative norms with the support from a key network member, such as the infant's father (Q8).
Influence of infant's father on breastfeeding
Many mothers agreed their baby's father was very supportive of breastfeeding (Table 3). Some fathers demonstrated their support by attending to the mother's needs as she was breastfeeding (Q9). Other fathers assisted with bottle feeds (formula or breast milk) to help with the mother's transition to work (Q10), so that the mother could sleep (Q11), or to give the mother respite from nursing and breast pain (Q12). Particularly when breastfeeding was not the norm, mothers emphasized that the support of their husbands allowed them to get through the challenges of breastfeeding (Q13, Q14).
Influence of Infant's Father on Breastfeeding
AA, African American.
In contrast, several mothers described the additional challenges faced when the baby's father was opposed to breastfeeding. One mother described the challenge when the father of a friend's baby opposed breastfeeding because he considered the breast a sexual organ (Q15). Another described her partner's concern that breastfeeding would impair his ability to bond with the infant (Q16).
Handling disagreement with one's network regarding breastfeeding norms
Several mothers reported that they disagreed with network members about whether or not to breastfeed (Table 4). Some mothers wanted to breastfeed despite network opposition and negative norms toward breastfeeding (Q17, Q18), and some described being determined to continue to breastfeed just to challenge the norm (Q19). Conversely, there were some mothers for whom the norm within the network was to breastfeed, but they had no desire to conform to the norm (Q20). When the norm was to breastfeed, some mothers described feeling pressured to breastfeed (Q21, Q22) and some felt strongly that they would be judged if they did not breastfeed or would be subjected to social shaming if breastfeeding was unsuccessful (Q23, Q24). However, other mothers were confident that their personal network would be supportive of their effort even if they were unable to nurse or had to stop sooner than intended (Q25, Q26).
Handling Disagreement with One's Network Regarding Breastfeeding Norms
AA, African American.
Effect of social norms that exist outside of one's network
Mothers described social norms regarding infant feeding outside of their personal social networks (Table 5). These norms could be categorized as “general public norms” and “workplace norms.” For the former, a large proportion of mothers felt that there was social stigma against breastfeeding in public, and that this could make them and/or their companions uneasy (Q27). For the latter, the challenges mothers felt in the workplace were largely dependent on their employers' social norms around breastfeeding. Some mothers, in anticipation of the difficulty of pumping breast milk at work, stopped breastfeeding or pumped additional breast milk before returning to work (Q28). Other mothers felt frustrated about inadequate breaks for pumping breast milk during the workday (Q29). On the contrary though, several mothers felt very supported in the workplace especially if their bosses or coworkers were also parents of young children (Q30, Q31).
Effect of Social Norms That Exist Outside of One's Network
AA, African American.
Discussion
Although prior studies have looked at women's motivation to breastfeed and the importance of social support in continuing breastfeeding,11,25 no other qualitative study has explored how a mother's social network and the norms inside and outside of her network influence breastfeeding. Our findings indicate that regardless of race or social network type, breastfeeding experience within the social network, fathers' opinions about breastfeeding, mothers' comfort with handling disagreement within her network about breastfeeding, and the social norms that exist outside of the network impact maternal breastfeeding decisions and build upon the prior work.
As expected, mothers in our sample were affected by the norms of their own social networks. Some mothers felt pressured to breastfeed by a variety of network members, including health professionals or relatives who were health professionals, family members who had breastfed and who believed that breastfeeding was the norm, and partners who were opposed to formula feeding. Other mothers cited social network pressures to not breastfeed, particularly from women who had not breastfed their own children and partners who were concerned about bonding with the infant or saw the breast as a sexual symbol. As expected, these opinions consistently affected mothers' decisions to initiate or continue breastfeeding.
Also consistent with prior studies indicating that matriarchal and partner influence play a major role in the initiation and continuation of breastfeeding,9,26 mothers in our study, in addition to relying on friends with prior childrearing experience, frequently cited their infants' fathers and grandmothers as most often influencing their decision to breastfeed. Interestingly though, for mothers in our study who wanted to breastfeed, support from these specific individuals was not always critical.
As important as social norms are in the decision to initiate and continue breastfeeding, several women described their capacity to defy their social network's norms. In some cases mothers had to strongly resist familial pressures to formula feed. Others though, reported that network members were supportive of changing the norm and encouraged them to breastfeed even if they had not breastfed themselves.
In many cases, to resist negative social norms, women had to look beyond their primary social supports. For example, although many women primarily sought advice on most infant-related concerns from their own mothers and relatives, when they were not supportive of breastfeeding, mothers who wanted to breastfeed looked to more distant network members for emotional or informational support specifically regarding breastfeeding.
This suggests that although close relative supports are important, if women are motivated to breastfeed, those outside a mother's inner circle, such as lactation consultants and peer educators, may be able to fill voids when the social norm is to not breastfeed. This also suggests that when one woman in a social network successfully breastfeeds, she is likely to be sought out as the support for other women in the same network. Ultimately, this has the promise of altering the norm of the entire network in favor of breastfeeding.
The importance of network supports in initiating and continuing breastfeeding has been well documented,9,26 but prior studies have not looked at mother's perception of the social implications of not breastfeeding. With the advent of Baby Friendly® hospitals and the recent emphasis on exclusive breastfeeding in birth hospitals, some women cited feeling social pressures to breastfeed and concern that if they struggled they would be perceived as a failure.
Both breastfeeding and nonbreastfeeding mothers experience shame through feelings of fear, humiliation, inferiority, and inadequacy. 27 Consistent with this, some mothers in our study cited feeling subject to social shaming if they failed to breastfeed. Interestingly though, other mothers acknowledged those pressures and yet still felt that if their attempts to breastfeed were unsuccessful, their own network would be accepting of their decision, citing previous support for women who had opted to formula feed after difficulties with breastfeeding. Although promoting breastfeeding to network members can lead to higher breastfeeding rates, if women feel shamed by the network, it may not only affect their decision to either initiate or continue breastfeeding, but also may make them less likely to rely on network support in other important realms, including infant safety.
Consistent with previous research,28,29 we found that social norms outside of a woman's personal social network influenced her decision to continue breastfeeding once she returned to work. Most important were the established norms regarding pumping breast milk in the workplace. When the workplaces had prior experience with women who pumped at work, mothers returning to work did not seem to view pumping as a barrier to continued breastfeeding. Similarly, even women who were the first employees in their company to pump felt accommodated and supported in the workplace if they had coworkers with personal or family experience with breastfeeding. Women who worked in places where pumping breast milk was not the norm reported the stress of finding time and a private location to pump as reasons for ceasing exclusive breastfeeding. Based on this, changes in workplace social norms regarding breastfeeding are likely to positively impact the number of women who continue to breastfeed after returning to work.
It is notable that based on our data, women with both exclusive and expansive social networks had similar experiences. Although one might expect those with expansive networks to find it easier to identify a peripheral network member for support, or to defy network norms, the fact that a single individual could provide adequate support seems to have negated these network differences. For example, a woman with an exclusive network, whose mother and sister were opposed to breastfeeding, may have continued breastfeeding because her husband supported it or vice versa. Similarly, those with exclusive networks reported looking outside their immediate network for support, specifically with breastfeeding. This is further evidence that even in close-knit families without a strong history of breastfeeding, new mothers can successfully breastfeed if given the appropriate encouragement as they are often willing to expand their networks specifically for this topic.
Limitations
We acknowledge that this study has several limitations. Although our study population included women with a wide spectrum of feeding practices, it was limited to those who self-identified as AA or Caucasian and who were from a single geographic region. In addition, qualitative research, although it can provide insight into a wide range of opinions, cannot be used to determine prevalence of any one viewpoint. Thus, although we reached thematic saturation, these results may not be generalizable to other groups or geographic regions. However, our findings are consistent with other qualitative studies.11,30,31 Nonetheless, further study in other geographic and racial/ethnic groups will be important to determine if the influence of social networks and norms is consistent.
Conclusions
Social networks and norms play a major role in influencing breastfeeding behavior among mothers of newborn infants and can have a constructive or destructive influence on the mother's decision to initiate or continue breastfeeding. However, as important as social norms are in the decision to initiate and continue breastfeeding, by relying on one network member to support them, mothers were often able to resist the opposing norms of their social network and sustain breastfeeding efforts. Any evidence-based recommendations or education regarding breastfeeding should not be limited to the mother alone but should also include individual network members who can provide strong support.
Footnotes
Disclosure Statement
No competing financial interests exist.
Funding Information
This project was supported by the National Institute for Minority Health and Health Disparities 1R01MD007702. The study sponsor had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. The authors have no other funding sources.