Lack of Knowledge

Most women in the United States are aware that breastfeeding is the best source of nutrition for most infants, but they seem to lack knowledge about its specific benefits and are unable to cite the risks associated with not breastfeeding.^61–63 For example, a recent study of a national sample of women enrolled in WIC reported that only 36 percent of participants thought that breastfeeding would protect the baby against diarrhea.⁶¹ Another national survey found that only a quarter of the U.S. public agreed that feeding a baby with infant formula instead of breast milk increases the chances the baby will get sick.⁶² In addition, qualitative research with mothers has revealed that information about breastfeeding and infant formula is rarely provided by women’s obstetricians during their prenatal visits.⁶⁴ Moreover, many people, including health professionals, believe that because commercially prepared formula has been enhanced in recent years, infant formula is equivalent to breast milk in terms of its health benefits;^62,63 however, this belief is incorrect.

Mothers are also uncertain about what to expect with breastfeeding and how to actually carry it out.^64,65 Even though breastfeeding is often described as “natural,” it is also an art that has to be learned by both the mother and the newborn. Skills in how to hold and position a baby at the breast, how to achieve an effective latch, and other breastfeeding techniques may need to be taught. Not surprisingly, some women expect breastfeeding to be easy, but then find themselves faced with challenges. The incongruity between expectations about breastfeeding and the reality of the mother’s early experiences with breastfeeding her infant has been identified as a key reason that many mothers stop breastfeeding within the first two weeks postpartum.⁶⁶ On the other hand, a misperception that many women experience difficulties with breastfeeding may cause excessive concern among mothers about its feasibility.^67–70

The perceived inconvenience of breastfeeding is also an issue; in a national public opinion survey, 45 percent of U.S. adults indicated that they believed a breastfeeding mother has to give up too many habits of her lifestyle.⁷¹ In addition, the commitment required by breastfeeding and difficulties in establishing breastfeeding are sometimes seen as threats to mothers’ freedom and independence.^72–76

Unfortunately, education about breastfeeding is not always readily available to mothers nor easily understood by them. Many women rely on books, leaflets, and other written materials as their only source of information on breastfeeding,^64,65,77 but using these sources to gain knowledge about breastfeeding can be ineffective, especially for low-income women, who may have more success relying on role models.⁷⁸ The goals for educating mothers include increasing their knowledge and skills relative to breastfeeding and positively influencing their attitudes about it.

Social Norms

In the United States, bottle feeding is viewed by many as the “normal” way to feed infants. Moreover, studies of mothers who are immigrants that examine the effects of acculturation have found that rates of breastfeeding decrease with each generation in the United States and that mothers perceive bottle feeding as more acceptable here than in their home countries.^79–86 Widespread exposure to substitutes for human milk, typically fed to infants via bottles, is largely responsible for the development of this social norm. After reviewing data from market research and studies conducted during 1980–2005, the U.S. Government Accountability Office (GAO) reported that advertising of formula is widespread and increasing in the United States.⁸⁷ Furthermore, the strong inverse association between the marketing of human milk substitutes and breastfeeding rates was the basis of the WHO International Code of Marketing of Breast-milk Substitutes (the Code).³⁵ The Code has been reaffirmed in several subsequent World Health Assembly resolutions. However, its provisions are not legally binding in the United States.

Certain cultural beliefs and practices also contribute to what women consider to be normal feeding practices,^76,88 although some of these practices are not recommended today. The mistaken belief that, for babies, “big is healthy,” can lead to both formula feeding and inappropriate early introduction of solid foods.^89,90 The false idea that larger babies are healthier is common among many racial and ethnic groups, and mothers who are part of social networks that hold this belief may be encouraged to supplement breastfeeding with formula if the infant is perceived as thin.⁹¹

Low-income Hispanic women in Denver, Colorado, were found to favor a practice called “best of both” (i.e., providing both breast milk and infant formula). Despite guidance that breast milk is the only source of nutrition a child needs for about the first six months of life, some women mistakenly see the “best of both” as a way to ensure that their babies get both the healthy aspects of human milk and what they believe to be the “vitamins” present in infant formula.⁶⁷ Another practice associated with cultural beliefs is the use of cereal in a bottle because of the misperception that it will prolong infants’ sleep.⁹⁰

Poor Family and Social Support

Women with friends who have breastfed successfully are more likely to choose to breastfeed. On the other hand, negative attitudes of family and friends can pose a barrier to breastfeeding. Some mothers say that they do not ask for help with breastfeeding from their family or friends because of the contradictory information they receive from these sources.⁷⁴

In many families, fathers play a strong role in the decision of whether to breastfeed.^92,93 Fathers may be opposed to breastfeeding because of concerns about what their role would be in feeding, whether they would be able to bond with their infant if they were personally unable to feed the baby, and how the mother would be able to accomplish household responsibilities if she breastfed.^64,72,94,95 Studies of African American families in which education on breastfeeding was directed at the father found a 20 percent increase in breastfeeding rates, indicating that paternal influences on maternal feeding practices are critically important in early decision making about breastfeeding.^92,96

Although they can constitute a barrier to breastfeeding, fathers can also be a positive influence. A randomized controlled trial of a two-hour prenatal intervention with fathers on how to be supportive of breastfeeding found a far higher rate of breastfeeding initiation among participants’ partners (74 percent) than among partners of controls (14 percent).⁹³ In another trial, 25 percent of women whose partners participated in a program on how to prevent and address common problems with lactation (such as pain or fear of insufficient milk) were still breastfeeding at six months, compared with 15 percent of women whose partners were informed only about the benefits of breastfeeding.⁹⁷ Among women who experienced challenges with breastfeeding, the program effect was even stronger, with 24 percent of participants’ partners breastfeeding at six months versus less than 5 percent of partners in the comparison group.⁹⁷

Embarrassment

A study that analyzed data from a national public opinion survey conducted in 2001 found that only 43 percent of U.S. adults believed that women should have the right to breastfeed in public places.⁹⁸ Restaurant and shopping center managers have reported that they would either discourage breastfeeding anywhere in their facilities or would suggest that breastfeeding mothers move to an area that was more secluded.^73,99,100 When they have breastfed in public places, many mothers have been asked to stop breastfeeding or to leave.⁹⁹ Such situations make women feel embarrassed and fearful of being stigmatized by people around them when they breastfeed.^{68,95,101,102} Embarrassment remains a formidable barrier to breastfeeding in the United States and is closely related to disapproval of breastfeeding in public.^76,102–104 Embarrassment about breastfeeding is not limited to public settings, however. Women may find themselves excluded from social interactions when they are breastfeeding because others are reluctant to be in the same room while they breastfeed.⁶⁵ For many women, the feeling of embarrassment restricts their activities and is cited as a reason for choosing to feed supplementary formula or to give up breastfeeding altogether.^104,105

In American culture, breasts have often been regarded primarily as sexual objects, while their nurturing function has been downplayed. Although focusing on the sexuality of female breasts is common in the mass media, visual images of breastfeeding are rare, and a mother may never have seen a woman breastfeeding.^106–109 As shown in both quantitative and qualitative studies, the perception of breasts as sexual objects may lead women to feel uncomfortable about breastfeeding in public.^68,101 As a result, women may feel the need to conceal breastfeeding, but they have difficulty finding comfortable and accessible breastfeeding facilities in public places.^110,111

Lactation Problems

Frequently cited problems with breastfeeding include sore nipples, engorged breasts, mastitis, leaking milk, pain, and failure to latch on by the infant.^64,112 Women who encounter these problems early on are less likely to continue to breastfeed unless they get professional assistance.^64,90 Research has found that mothers base their breastfeeding plans on previous experiences, and resolution of these problems may affect their future decisions about feeding.^64,90

Concern about insufficient milk supply is another frequently cited reason for early weaning of the infant.^90,113–116 One national study on feeding practices found that about 50 percent of mothers cited insufficient milk supply as their reason for stopping breastfeeding.¹¹² Having a poor milk supply can result from infrequent feeding or poor breastfeeding techniques,^{115,117–119} but lack of confidence in breastfeeding or not understanding the normal physiology of lactation can lead to the perception of an insufficient milk supply when in fact the quantity is enough to nurture the baby.^120,121

Women report receiving conflicting advice from clinicians about how to solve problems with breastfeeding.^94,122,123 Successful initiation depends on experiences in the hospital as well as access to instruction on lactation from breastfeeding experts, particularly in the early postpartum period. Most problems, if identified and treated early, need not pose a threat to the continuation of successful breastfeeding.^124–128

Employment and Child Care

Employed mothers typically find that returning to work is a significant barrier to breastfeeding. Women often face inflexibility in their work hours and locations and a lack of privacy for breastfeeding or expressing milk, have no place to store expressed breast milk, are unable to find child care facilities at or near the workplace, face fears over job insecurity, and have limited maternity leave benefits.^{13,101,116,129–131} In 2009, the Society for Human Resource Management reported that only 25 percent of companies surveyed had lactation programs or made special accommodations for breastfeeding.¹³² Small businesses (fewer than 100 employees) are the least likely to have lactation programs, and whether the workplace is large or small, infants are generally not allowed to be there.¹³² Many mothers encounter pressure from coworkers and supervisors not to take breaks to express breast milk, and existing breaks often do not allow sufficient time for expression.¹³³ When mothers who do not have a private office at work do not have a place to breastfeed or express breast milk, they may resort to using the restroom for these purposes, an approach that is unhygienic and associated with premature weaning.^134–137

Lack of maternity leave can also be a significant barrier to breastfeeding. Studies show that women intending to return to work within a year after childbirth are less likely to initiate breastfeeding, and mothers who work full-time tend to breastfeed for shorter durations than do part-time or unemployed mothers.^129,138 Women with longer maternity leaves are more likely to combine breastfeeding and employment.¹³⁹ In a survey of 712 mothers, each week of maternity leave increased the duration of breastfeeding by almost one-half week.¹⁴⁰ Jobs that have less flexibility and require long separations of mother and baby further complicate breastfeeding.¹³¹ Hourly wage workers face different challenges than salaried workers, as the former typically have less control over their schedules, and their pay may be reduced if they take breaks to express breast milk.¹⁴¹

Barriers Related to Health Services

Studies have identified major deficits relevant to breastfeeding in hospital policies and clinical practices, including a low priority given to support for breastfeeding and education about it, inappropriate routines and provision of care, fragmented care, and inadequate hospital facilities for women who are breastfeeding.^142,143 A recent report that summarizes maternity practices related to breastfeeding in 2,687 hospitals and birth centers in the United States indicated that these practices are often not evidence based and frequently interfere with breastfeeding.⁵² For example, 24 percent of birth facilities in the survey reported giving supplemental feeding to more than half of healthy, full-term, breastfed newborns during the postpartum stay,⁵² a practice shown to be unnecessary and detrimental to breastfeeding.^144,145 In addition, 70 percent of facilities that participated in the survey reported giving breastfeeding mothers gift packs containing samples of infant formula,⁵² which can have a negative influence on both the initiation and duration of breastfeeding.^146–149

Separating mothers from their babies during their hospital stay has a negative impact on the initiation and duration of breastfeeding,^150,151 yet DiGirolamo and colleagues¹⁵² reported that only 57 percent of U.S. hospitals and birth centers allowed newborns to stay in the same room as their mothers. In addition, an inverse relationship exists between breastfeeding rates and invasive medical interventions during labor and delivery, such as cesarean section.¹⁵³ Cesarean delivery is associated with delayed skin-to-skin contact between mother and baby, increased supplemental feeding, and separation of mother and baby, all of which lead to suboptimal breastfeeding practices.^153–157 Nevertheless, cesarean births are not rare; preliminary data for 2007 indicate that almost one-third of women (32 percent) in the United States gave birth by cesarean section in that year, which is higher than the prevalence of 21 percent reported just 10 years prior in 1997.^158,159

Obstetrician-gynecologists, pediatricians, and other providers of maternal and child care have a unique opportunity to promote and support breastfeeding. Although pregnant women and mothers consider the advice of clinicians to be very important with regard to their decisions about breastfeeding, clinicians often underestimate their own influence on breastfeeding.^160,161 Clinicians report feeling that they have insufficient knowledge about breastfeeding and that they have low levels of confidence and clinical competence in this area.¹⁴³ A recent survey of pediatricians showed that many believe the benefits of breastfeeding do not outweigh the challenges that may be associated with it, and they reported various reasons to recommend against breastfeeding.¹⁶²

Physicians who are ambivalent about breastfeeding or who feel inadequately trained to assist patients with breastfeeding may be unable to properly counsel their patients on specifics about breastfeeding techniques, current health recommendations on breastfeeding, and strategies to combine breastfeeding and work.^{90,101,143,161,163–165} Furthermore, a study of clinicians’ knowledge and attitudes about breastfeeding found that some clinicians used their own breastfeeding experiences to replace evidence-based knowledge and recommendations they shared with their patients.¹⁶⁰