Influencers of women's choice and experience of exclusive formula feeding in hospital
Introduction
Breastfeeding is the optimal infant feeding method, with health risk reduction and improved outcomes associated for both breastfed infants and breastfeeding mothers (Lyons et al., 2020; Bode, 2018; Mosca et al., 2017; Victora et al., 2016). Gaps in knowledge and understanding remain, related to the reasons women may choose exclusive infant formula over breastfeeding, and how health professionals can improve supportive care for this cohort. The limited research conducted with women who choose formula feeding (FF) has often focused on how midwives and other health professionals could have influenced and supported women to breastfeed. To illustrate, an American qualitative study sought to understand the influence of culture on women's infant feeding decisions, to enhance efforts to “reduce breastfeeding disparities” (Fischer and Olson, 2014, p.209). A British qualitative study also examined influencing factors, in which health professionals and mothers reinforced the importance of knowledge and support. Findings suggested that resources and recognition were needed for health professionals to increase support “with the aim of increasing breastfeeding duration” (Brown et al., 2011, p.1993). Another qualitative study with Chinese health professionals and mothers found the perception of insufficientbreastmilk was a key reason for FF, plus low maternal confidence, misconceptions about infant feeding, inadequate breastfeeding facilities, workplace inflexibility, and limited understanding of the health benefits of breastfeeding (Zhang et al., 2015).
Canadian women who chose FF – in addition to, or instead of, breastfeeding – were interviewed to determine their reasons for this decision (Ludlow et al., 2012). Although the research question focused on what attitudes, beliefs and values influenced the decision not to breastfeed, the interview question was changed from ‘why did you choose not to breastfeed?’ to ‘why did you choose to formula feed?’ to avoid negative connotations. These women balanced risks in order to identify as ‘good mothers’, under themes of family functioning, infant health and personal issues. Qualitative research with FF mothers has also focused on specific cohorts, such as: Danish women's experiences and difficulties “to face the world with a bottle” after relinquishing breastfeeding (Larsen and Kronborg, 2013, p.848); American women's FF experiences in a Special Supplemental Nutrition Program, who felt judged and underserviced due to their feeding decision (Almeida et al., 2020); and the challenges for HIV-positive Brazilian women exclusively formula feeding on medical advice (MacCarthy et al., 2013).
A systematic review (Lakshman et al., 2009) focused on parents’ experiences of FF, confirming resultant emotions of guilt, anger, uncertainty, and a sense of failure. Mothers felt they did not receive sufficient information and support from healthcare providers. Similarly, an Australian mixed methods study of regional services confirmed that services supporting breastfeeding were comprehensive, while education and professional support services related to FF were lacking in comparison (Hegedus and Mullan, 2015). Although Ireland is recognised as having a culture that is supportive of FF (Leahy-Warren et al., 2017), a prospective observational study with 450 Irish mothers sought to gain insight into FF practices, reasons for this choice, sources of information, and support needs (Tarrant et al., 2013). Family (39%) was cited as the most frequent source of information for those who formula-fed, compared to health professionals (15.8%). With 81.8% of infants in this Irish study receiving formula by 6 weeks post-birth, the perception of FF as convenient, a pre-pregnancy decision, and to avoid public embarrassment were the main reasons for choosing FF.
The Council of Australian Governments (COAG, 2019a) released strategic directions for Australian maternity services asserting that “women are the decision-makers in their care and maternity care should reflect their individual needs” in alignment with values of safety, respect, choice and access (p.7). Respect for women's choices and preferences are paramount, and midwives as a key support for childbearing women must reflect these values. The Nursing and Midwifery Board of Australia (NMBA, 2018) standards for midwifery practice incorporate these values, with Standard Two stating that a midwife “engages in professional relationships and respectful partnerships” (p.4) through supporting women's choices.
Support for breastfeeding is promoted through the Australian Breastfeeding Association, and the Baby Friendly Health Initiative (BFHI) Australia which commenced in 1995 and continues under the governance of the Australian College of Midwives. Although the Australian National Breastfeeding Strategy (COAG, 2019b) offers a framework for an enabling environment and support for breastfeeding, the concept of supporting choice in infant feeding must be acknowledged. A woman-centred model acknowledges choice and includes support for all forms of infant feeding. As highlighted in this introduction, current limited evidence around women's experiences with FF is between 5 and 10 years old. There have been no recent studies focused on the experiences of Australian women who chose exclusive FF. Given international findings around inadequate information provision, negative emotions, and less-than-ideal support where parents have decided to use formula (Fallon et al., 2016), it is timely to investigate women's contemporary experience. Therefore our study aim was to explore what influenced women's decision to exclusively formula feed, and their experiences with formula feeding within a maternity hospital environment.
Section snippets
Design
This mixed methods study used a cross-sectional exploratory survey design. Cross-sectional studies are known for their utility in providing a snapshot of phenomena at a point in time (Kesmodel, 2018). Pragmatic theory supports the intentional scaffolding of mixed methods research, using both qualitative and quantitative approaches to enable more detailed exploration of complex phenomena focusing on answers to research questions; in this case, what are the influencing factors and experiences of
Results
Data collection occurred from November 2018 to May 2020. A total of 208 women met inclusion criteria and of these, 102 women participated, a 52% response rate. The participants’ ages ranged from 16 to 44 years, the majority self-identified as White/Caucasian (75.5%, n=77) and had two or more children (77.5%, n=79); full demographics are presented in Table 2. Findings from the qualitative component of the study are reported under two main headings: ‘What influenced women's choice to formula
Discussion
To our knowledge, this is the first study that has sought to understand the experiences of women who chose to exclusively formula feed their baby in hospital. Findings reveal new knowledge about what influenced their feeding choice and provide insight into their experiences of exclusive FF whilst in hospital, offering evidence on how midwifery care and physical resources intersect with the start of women's infant feeding journey.
Multiparous women indicated that previous breastfeeding
Conclusion
This study has provided evidence regarding what influenced women's decision to exclusively formula feed and their experiences in the immediate postpartum period. For many multiparous women, previous breastfeeding experiences had an influence on choosing to formula feed in a subsequent pregnancy, reminding health professionals of the importance of education, support, resources and debriefing for breastfeeding women, especially during their first lactation journey. Multiparous women were also
Ethical approval
Approval to conduct this study and publish findings was granted by the study hospital (approval number QA28061).
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Courtney Barnes: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration. Yvonne Hauck: Conceptualization, Methodology, Formal analysis, Resources, Writing – original draft, Writing – review & editing, Supervision. Kelly Mabbott: Formal analysis, Investigation, Data curation, Writing – review & editing. Kirsty Officer: Formal analysis, Investigation, Data curation, Writing – review
Declaration of Competing Interest
None declared by all authors.
Acknowledgments
We would like to thank the study participants, who were gracious in openly sharing their experiences with formula feeding in hospital post birth.
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