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Young mothers’ decisions to initiate and continue breastfeeding in the UK: tensions inherent in the paradox between being, but not being able to be seen to be, a good mother

30 May, 2014

Young mothers’ decisions to initiate and continue breastfeeding in the UK: tensions inherent in the paradox between being, but not being able to be seen to be, a good mother

In the UK and other developed nations, adolescent mothers are among those least likely to breastfeed, yet they and their children would potentially benefit more from breastfeeding than advantaged groups. This research explores the ways in which a small group of UK adolescent mothers conceptualise their decisions to breastfeed and experience breastfeeding in their communities.

Louise Hunter1 MA(Oxon), BSc, RM. Julia Magill-Cuerden2 PhD, MA, DN, PGDip Ed, RM, RN. 

1. Senior midwifery lecturer, College of Nursing, Midwifery and Healthcare, University of West London, Brentford TW8 9GA England. Email: louise.hunter@uwl.ac.uk 

2. Emeritus scholar and associate lecturer, College of Nursing, Midwifery and Healthcare, University of West London, Brentford TW8 9GA England. Email: julia.magill-cuerden@uwl.ac.uk

 

Abstract 

Background. In the UK and other developed nations, adolescent mothers are among those least likely to breastfeed, yet they and their children would potentially benefit more from breastfeeding than advantaged groups.

Aim. To explore the ways in which a small group of UK adolescent mothers conceptualise their decisions to breastfeed and experience breastfeeding in their communities.

Method. A total of six focus groups or interviews with 15 mothers aged 16 to 20. Participants were recruited at young parent groups in Oxfordshire, England. Ethical approval was obtained from the relevant NHS and university authorities.

Findings. Young UK women are acutely aware of the stigma attached to young motherhood in the UK and consider that breastfeeding can help overcome this through its associations with good mothering. Although some did not initially want to breastfeed, they developed a desire to do so as their pregnancy progressed. In common with older breastfeeding mothers, young mothers in the UK rarely feel able to breastfeed in public or in front of male family members. This creates conflict and distress for young mothers, who, as new adults, need to be judged positively, and accepted by and integrated into their families and communities. Young mothers identified a paucity of support for breastfeeding within their social networks, and found maintaining exclusive breastfeeding difficult.

Implications. The paradox between being, but not being able to be seen to be, a good mother creates problems and exacerbates existing tensions between young women and their families and communities. An understanding of the conceptual framework used by young mothers in the UK who decide to breastfeed, and of the difficulties they face, may enable midwives to provide appropriate, targeted advice and support for this group.

Key words: Young mothers, breastfeeding decisions, breastfeeding experiences, cultural influences, evidence-based midwifery

 

Introduction

Breastfeeding rates in the UK fall short of the WHO 2025 target for at least 50% of babies to be exclusively breastfed up to six months of age, with only 1% of mothers currently exclusively breastfeeding for that long (Health & Social Care Information Centre, 2012; WHO, 2012). Within the UK and other developed nations, women aged under 20 are the least likely to initiate breastfeeding, and the breastfeeding rate for this group declines more steeply over time (Hall Smith et al, 2012; Health & Social Care Information Centre, 2012). Increasing breastfeeding rates among young mothers and other disadvantaged groups is a health service priority in the UK, particularly as the health benefits that breastfeeding confers could arguably have more impact among populations with greater health and social needs (Dyson et al, 2006). However, although it is widely held that young mothers require additional support in order to be able to breastfeed (Department of Health, 2004; WHO, 2003), a review of relevant research literature from 1990 to 2013 revealed that little is known about how teenage mothers conceptualise and experience breastfeeding (Hunter, 2014). 

Background

Young mothers in the UK and other developed, English-speaking nations (the US, Canada, Australia) are thought to be less likely to breastfeed because many come from socio-economically disadvantaged cultures where artificial feeding is regarded as usual, convenient and safe; where breasts are overwhelmingly linked with sexual identity and activity; and where breastfeeding, particularly in public, is held to be at best embarrassing and at worst a morally degrading behaviour (Dyson et al, 2010; Shaw et al, 2003). The resulting dominance of formula-feeding has led to a lack of embedded knowledge about breastfeeding being available to young mothers (Hall Smith et al, 2012). However, there is evidence to suggest that young women are aware that breastfeeding is best for their babies’ health and intend to breastfeed, but either never initiate it, or stop very soon after giving birth (Hunter, 2008; Mossman et al, 2008; Wambach and Koehn, 2004). 

In addition to formulating an intention to breastfeed against cultural norms and expectations, young mothers are making these decisions as people new to adult life. Adolescents crave acceptance and approval as adults, but yearn for the dependency and protection of youth (Frankel, 1998). In this context, childbirth as a rite of passage ending with incorporation of the new adult self into the community (Wilkins et al, 2009) can be seen to be particularly pertinent to young mothers. Their unique developmental and psychological needs might lead them to conceptualise feeding decisions differently to older mothers and to encounter different challenges.

As part of a larger project which aimed to develop an intervention to improve inpatient care for young mothers intending to breastfeed (Hunter, 2014), this study explores the way in which a small group of UK teenage mothers conceptualise their breastfeeding decisions. It is suggested that insight into this process is necessary for the development of effective breastfeeding support for this group.

Method

This qualitative research employed a constructivist perspective, viewing reality as something that is constructed by the people who live it (Schwandt, 2000). Focus groups were selected as an ideal medium to enable participants to explore and articulate the concepts and frameworks informing their breastfeeding decisions and experiences. A constructivist approach acknowledges that the understandings conveyed by the participants may be distorted by the researcher, who may not share the same cultural references. Measures were taken, therefore, to ensure the results were as close as possible to the participants’ reality. These included the researchers reflecting experiences and concepts back to the participants to ensure they had been understood correctly, and allowing the participants’ accounts to challenge and change their own pre-existing ideas. Strategies such as inductive analysis and retrospective member checking were also used (Charmaz, 2000; Schwandt, 2000).

 

Participants/setting 

Six focus groups were set up at pre-existing young parent groups in a mix of city, town and rural locations in Oxfordshire, England between July and November 2010. Using different groups enabled cross-comparisons to be made (Morgan, 1988). Although generally considered a prosperous area, Oxfordshire has significant pockets of social deprivation, with its city ranked 131/354 in the English Index of Multiple Deprivation 2010 (Oxford City Council, 2013). The young parent groups from which the participants were drawn were located in deprived areas. 

Young mothers were eligible to take part if they were aged 16 or over – 16-year-olds are considered competent to give consent on their own account by the Medical Research Council (2004) – had given birth at age 19 or under, and had considered breastfeeding or breastfed. They needed to have a good level of spoken English. Exclusion criteria included any young woman whose young parent group leader considered would be distressed by taking part. The researcher visited young parent groups to invite mothers to participate if, after an initial explanation from their group leader, they agreed to this visit. Full understanding of the purpose of the study was discussed and participant information leaflets distributed. Those interested in taking part were then invited to return for the focus group on a mutually convenient day. Individual discussions were held with each participant on the day of the group prior to consent being sought. It was made clear that withdrawing or withholding consent would not compromise future care (Matthews, 2006). Participant confidentiality was protected by keeping contact details and demographic information separately from focus group transcripts. Pseudonyms were assigned to all transcripts. Ethical approval was obtained from the local NHS research ethics committee and the researchers’ university.

 

Data collection

The focus groups were facilitated by the first author of this paper, who was unknown to the participants before the start of the study. Data saturation was considered to have been reached after no substantively new themes were introduced by the final group. The leaders of each of the young parent groups, with agreement of the young women, sat in on the focus groups. As the participants were used to their presence during meetings and as the discussion was not concerned with their role, it was considered that they would assist in normalising the experience. 

 

Data analysis

Data were recorded, transcribed verbatim, coded inductively and analysed thematically. Transcripts were analysed line by line and emerging codes entered into a coding book. Similar codes were then linked together to form sub-themes, which were then grouped into themes. Coding and analysis did not start until all data had been collected. Selected transcripts were analysed by a third person to check validity of the emerging codes and themes (Lincoln and Guba, 1985). Copies of the transcripts were then cut and sorted under the appropriate theme. This exercise was considered an important way of measuring different points of view, confirming concepts and interpretations, and ensuring that the researchers had not distorted the data to fit their own interpretation of events (Silverman, 2006). 

Although some of the original participants responded positively to an invitation to take part in the retrospective member checking, they did not attend on the day and a different group of young mothers took part. As the member checking took place up to six months after the original focus groups, many of the original participants had ceased to attend young parent groups and moved on with their lives. However, the young mothers involved in the retrospective checking recognised and identified with the codes and themes presented to them.

Findings

Participant demographics

A total of 15 participants aged between 16 and 20 attended the focus groups. Four of the groups had between two and five participants. On two occasions, only one person attended and an interview was held, as it was important to capture all possible data to give voice to this vulnerable and minority group (Marlowe, 2008). Although below the often quoted focus group ideal of six to 10 participants (Curtis and Redmond, 2007), these attendance levels align with other research with young mothers, who are particularly difficult to engage (Dykes et al, 2003). Each group or interview lasted between one and two hours. Young parent group leaders were not present during the interviews.

A total of 12 participants were white British, one was Portuguese, and two were of mixed white/black African heritage. A total of 11 stated that they had completed their education, and four planned to return to school or college. Of the participants, 13 were mothers, with babies aged from two weeks to 21 months. Two were approaching the end of their pregnancies when they first attended a focus group. The group in which these women took part (Focus Group (FG) 1) was reconvened after they had given birth, in order to capture their experiences of breastfeeding (these two groups are counted as one in the analysis as the same women attended on both occasions, and the second group was a continuation of the discussion started in the first). All but one of the participants was primiparous. As members of established young parent groups, the participants in each focus group knew one another socially. A summary of the characteristics of each group is presented in Table 1 (below). The focus groups are numbered one to four. The two ‘groups’ with only one participant are designated Interview (I) 1 and 2.

Table 1. Focus group characteristics Table 1. Focus group characteristics

Two principle themes of personal, and network and community influences on breastfeeding decisions and experiences were identified. In the personal theme, sub-themes of ‘breastfeeding and good mothering’, and ‘breastfeeding and nurturing’, emerged. Sub-themes in network and community influences were ‘problems of community integration’, ‘family support – an emotional minefield’, and ‘the lure of the bottle’. 

 

Personal influences on breastfeeding

Breastfeeding and good mothering

The participants were very aware of the stigma attached to young motherhood. This was highlighted by their admission of making assumptions and judgements about young mothers in the past:

“‘Cos I used to be like that [disapproving of young mothers]. I won’t lie…” (Avril, FG1). 

The young women described going to great lengths to present themselves as respectable citizens, including being deliberately vague about their addresses, so they weren’t stereotyped as ‘council estate’ teenage mothers, and taking their partners to antenatal appointments, so people could see that they were in a relationship.

In this context, breastfeeding was seen as an act that would demonstrate that the young person was a capable and worthy mother. One interviewee expressly linked her decision to breastfeed with a need to prove her mothering credentials:

“I think also because I was a teenager I sort of wanted [to breastfeed] to sort of prove that I was gonna be a good mum” (Sarah, I2).

By choosing to breastfeed, the young mothers felt that they were putting their babies first, as it was healthier for them (Lucy, FG2). They rarely mentioned any benefits of breastfeeding for themselves – only one group cited the fact that it helps women lose weight (FG3). In fact, breastfeeding was held to have several disadvantages for mothers – it could be painful, stressful and difficult:

“It was one of the hardest things I’ve done” (Becky, FG1). 

Breastfeeding was also seen to be a sign of good mothering because it promoted ‘closeness for you and your baby’ (Jemma, FG3), creating a bond that formed an important part of participants’ maternal identity and boosting self-esteem:

“…but if you really think about it, if you’re breastfeeding, all your baby really needs is you… Because you’re his comfort, his food. You know, you’ve got everything he needs” (Becky, FG1).

 

Breastfeeding and nurturing

In order to want to breastfeed, participants described how they had to learn to see bodily contact as a nurturing, rather than a purely sexual activity. Only one participant, who had grown up around breastfeeding, saw it as the normal and natural option (Avril, FG1). For the others, a change in attitude generally happened over the course of the pregnancy, as the drive to be a good mother overcame an initial dislike of the idea of breastfeeding. This process is particularly evident in the narratives of Sarah (I2) and Shannon (FG1). Sarah describes how, when asked about breastfeeding in early pregnancy: 

“I was like ‘oh no, I don’t like it, I don’t like it’” (Sarah, I2).

This attitude changed as she learnt about breastfeeding benefits and developed a relationship with her unborn child:

“…and then, sort of, as I grew bigger, and then obviously saw the scan, I thought ‘oh no, I do wanna’… and then I think learning about it made me realise that I did wanna do it” (Sarah, I2).

Shannon described rejecting the idea of skin-to-skin contact when she first heard about it, as her baby would be covered in ‘goo stuff’. She also struggled to overcome her association of breasts with sexuality:

“I can see my baby’s dad latched onto the other one” (Shannon, FG1). 

Again, however, she came to associate bodily contact and breastfeeding with nurturing and being a good mother:

“Um, well my neighbour… she didn’t breastfeed… I look at her relationship with her daughter… they don’t seem as close… I wanna breastfeed – I want to hold my baby straight away and stuff like that” (Shannon, FG1).

 

Network and community influences on breastfeeding decisions and experiences

Problems of community integration

It was apparent that a deeply embedded taboo about feeding in front of other people, particularly men, made being integrated into the community as a breastfeeding mother difficult. Participants described oscillating between acts of bravado and defeat. Avril was able to follow Shannon’s example and breastfeed in a shopping centre:

“Shannon whipped it out and I thought ‘if she can do it, I’m doing it’” (Avril, FG1).

But the prospect of feeding her baby in front of other people’s partners at a breastfeeding clinic is too much for one particpant:

“There was all these blokes there. I was just like – ‘I’m 18, and I didn’t want to’ – you know… So I just sort of said: ‘Oh, we’re going for a walk and we’ll come back.’ And I just sort of ran out of there” (Sarah, I2).

The taboo against public breastfeeding extended to feeding in front of male family members. Some young women were even embarrassed to feed in front of their partners initially. Far from bringing praise of their mothering skills, breastfeeding could isolate the new mothers from their families, causing great distress:

“[My mother]... told me I couldn’t breastfeed, and told me that if I wanted to breastfeed I had to go upstairs… I had to go and sit in the car… it was almost like they rejected me” (Becky, FG1).

Some felt that they had to choose between breastfeeding and spending time with their families:

“…I wanted to be on my own doing it [expressing], but I didn’t want to be on my own like missing out on that time with everyone – like I could hear them all laughing downstairs and I was upstairs” (Sarah, I2).

This feeling of isolation was further compounded by the perception that no one was able to provide help and support:

“...at night time I was the only one that could get up and do it – I just thought that was quite hard that no one else could like get up and do it – it had to be me” (Lottie, FG3).

 

Family support – an emotional minefield

Receiving support and encouragement from their families and friends helped the young mothers feel valued and accepted, and gave them the strength to continue breastfeeding when difficulties or opposition were encountered: 

“Cos like when I was in hospital… I was gonna give up, but if it wasn’t for him [partner] I think I would of, but he was really encouraging, he kept me going” (Vicky, FG3).

Partners and families were not always perceived to be supportive, however. Lack of support was often attributed to a lack of knowledge about breastfeeding or, in the case of some partners, to prevailing cultural norms:

“He preferred me to bottle-feed. It’s just a man thing, isn’t it?” (Rachel, I1). 

“She [foster mother] didn’t really breastfeed her kids, so she was giving me the option obviously – it was my choice, so, but she tried helping out as much as she could… like if I needed to express she would hold the baby… but she wasn’t very helpful – she just kind of let me do it myself, sort of thing” (Jemma, FG3).

Furthermore, not being able to participate in feeding their babies could exclude partners: 

“Partners don’t get the bond that you get” (Clare, FG3).

Family relationships could be emotionally charged, making it difficult for mothers in particular to give, and daughters to receive, advice. Even though her mother had breastfed, one participant found it difficult to accept support from her:

“I’m much happier now I’m not at home. Like me and me mum have got a much better relationship now, ‘cos we’re not arguing all the time” (Tanya, FG4).

Participants in two groups felt that, even when they had a more positive relationship, their mother was not the right person to support them with breastfeeding:

“I think my grandma’d be better, actually showing me how to do it, ‘cos my mum’s really funny – about stuff like that. She gets – she’s – she gets really embarrassed” (Shannon, FG1). 

In some cases, it was the young women who were embarrassed to discuss breastfeeding with their mothers and would rather talk to a healthcare professional: 

“Yea, I don’t have a bond with them or anything like that” (Lottie, FG3).

It appears that these mothers find it easier to accept support from health professionals, not only because discussing bodily functions with their mothers is potentially embarrassing, but also because by identifying breastfeeding with good mothering, they have made an emotional commitment to breastfeeding success, and are more likely to be overwhelmed by their emotions in front of those closest to them. The participants were asked about receiving advice from lay breastfeeding supporters, but regarded this idea with suspicion, categorising anyone who wasn’t either family, friend or professional as a ‘stranger’ who they wouldn’t want to talk to.

 

The lure of the bottle

Initiating feeding was one thing, but sustaining it in an environment that was often unsupportive and where breastfeeding separated new mothers from their families was altogether different, particularly for mothers who left hospital expressing breastmilk. Regular expressing was ultimately an unsustainable commitment:

“And then in the end I just couldn’t be arsed, and had enough when I got home, after three weeks, I just shoved him on the bottle” (Jemma, FG3). 

Some young women felt that exclusive breastfeeding was not sustainable in their day-to-day lives, but that combining it with bottle-feeding created a perfect feeding method:

“I’d do both bottle and breast [if she had another baby]… I’d find it easier. It wouldn’t always be relied on me” (Clare, FG3).

Mixed feeding was seen as an option that enabled new mothers to integrate fully into their families and communities. It was also considered important that babies become ‘used to’ bottle-feeding, as breastfeeding could not be allowed to continue for too long. One participant, who had grown up around breastfeeding felt that early weaning was essential:

“It’s kind of frowned on to breastfeed from three or four months” (Avril, FG1).

The participants, therefore, disagreed with the practice of not offering formula supplements in hospital:

“I think you should [be offered formula in hospital], and then you can choose what you want to do…” (Lottie, FG3).

Discussion 

The focus group format employed in this research generated some forthright discussion and opinions. The data support previous findings that young mothers choose to breastfeed because it is ‘best for baby’, and promotes bonding. Support from families and significant others is identified in other UK studies as an important component of breastfeeding success (Hall Moran et al, 2007; Shaw et al, 2003). The young mothers’ descriptions of finding breastfeeding in public challenging are consistent with the experiences of some older mothers (Mahon-Daly and Andrews, 2002). This study adds to the growing body of research from the UK and Australia highlighting the fact that feeding in front of men, even close family members, is taboo (Stapleton, 2010; Benson, 1996).

In this study, these themes are embedded in an overriding need expressed by young mothers to be a good mother and integrated as such into their families and communities. The drive to be a good mother enabled participants to overcome negative attitudes towards breastfeeding during their pregnancies. Their need for family and community integration made exclusive breastfeeding difficult to maintain. The paradox of breastfeeding being a hallmark of good mothering and yet something that cannot be seen is particularly problematic for young mothers: evident throughout is the narrative of young women as ‘rookie’ adults and mothers, wanting to be judged positively and seeking affirmation and acceptance from those close to them.  

The association of breastfeeding with good mothering is well established among older mothers (Marshall et al, 2007), and the stigma of young motherhood makes young women keen to portray themselves as good mothers (Graham and McDermott, 2006). Breastfeeding has not, to the authors’ knowledge, been specifically associated with good mothering in other qualitative research with young women. Earlier studies of young mothers’ attitudes to breastfeeding in Canada and the UK have pointed towards this idea, in that young women suggest their babies’ needs are paramount (Brown et al, 2011; Nelson, 2009). It may be that the need to be a good mother is particularly strong in younger mothers, because adolescents are developing fragile identities as new adults, and because they fear that being labelled a ‘bad’ mother will result in their babies being taken into care (Price and Mitchell, 2004; Frankel, 1998). 

A recent UK study of factors influencing the infant-feeding decisions of socio-economically deprived pregnant teenagers presents a different view, finding many young women viewed breastfeeding as a morally inappropriate behaviour practised by lazy, ‘loose’ women (Dyson et al, 2010). Dyson et al (2010) do not state what stage of pregnancy the participants in their study had reached, but the negative views could indicate the women were earlier in their pregnancies.

Also highlighted here is the emotionally charged and delicate nature of many mother/daughter relationships, suggesting that young mothers might prefer to receive breastfeeding advice and support from health professionals. Friendship and support from other young mothers also emerge as important by helping to increase confidence.

Limitations

The number of participants was small, self-selecting, and all attended young parent groups. This, and the limited geographical area of the research, affect the transferability of the findings to other settings. In keeping with a constructivist approach, the researcher was the instrument of data collection and analysis (Parahoo, 2007). This could have compromised internal validity, although transcripts were reviewed and codes agreed with a third person to guard against this. 

Implications for practice

The finding that some young women develop a desire to breastfeed over the course of their pregnancies reinforces advice that women should not be asked about their feeding intentions at the beginning of pregnancy, but involved in open discussions about breastfeeding (UNICEF, 2010). 

When discussing feeding, midwives need to consider the difficulties that young mothers face maintaining breastfeeding when it isolates them from their families or creates added tensions in fragile relationships. Advice needs to fit into the context of young mothers’ lives and diffuse, rather than exacerbate, the emotional strain they are under. 

A strong inclination towards mixed feeding among young breastfeeding mothers is also mirrored in other UK and US studies and early formula supplementation is common among this group (Grassley and Sauls, 2011; Wambach and Koehn, 2004). Although breastmilk expression would provide a much healthier alternative, current findings suggest that prolonged breastmilk expression is problematic for this group. The challenges young mothers need to overcome in order to maintain breastfeeding have led to the suggestion that mixed feeding might be a more realistic and practical goal for some (Nelson, 2009). It would certainly appear that in order for more young women to be able to breastfeed exclusively either creative solutions must be found to the stresses and dilemmas they face or attitudes and conventions within society at large need to be challenged and changed.

Conclusion

Young mothers associate breastfeeding with good mothering. Those who choose to breastfeed struggle to balance the competing concepts of their ideal for good mothering and the reality of being an adolescent adjusting to parenthood within a social milieu intolerant of breastfeeding in public and lacking the heritage to provide adequate breastfeeding support. The views expressed by this small number of young UK mothers suggest that midwives need to understand and address the developmental, conceptual and community frameworks which shape young mothers’ breastfeeding decisions and experiences if effective support is to be offered to this group.

 

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