To foster optimal health outcomes for mothers and children, the World Health Organization (WHO, 2023) recommends that women exclusively breastfeed their infants for the initial 6 months. Following this period, it is advised to introduce safe and nutritionally appropriate complementary solid foods while continuing the practice of breastfeeding for 2 years and beyond. However, a recent report found that health systems often do not provide adequate breastfeeding protection, promotion and support (Pérez-Escamilla et al, 2023).
There is evidence that highlights the vital role health professionals have in supporting and educating women to initiate and continue breastfeeding (Trivedi, 2018). Women initiating breastfeeding who discuss their concerns with health professionals are more likely to breastfeed for a longer duration compared to those who do not (Baño-Piñero et al, 2018). Similarly, Clark and Price showed that interpersonal relationships with health professionals can facilitate empowerment to overcome breastfeeding challenges (Clark and Price, 2018). However, much of this research is conducted while women want to initiate breastfeeding or are breastfeeding an infant.
Women who continue to breastfeed beyond infancy (age of 1 year) have reported a shift in health professionals' guidance towards rapid weaning and having to endure unmet health needs because of a professional's lack of knowledge (Jackson and Hallam, 2019). Cisco (2017) found that mothers who frequently discuss breastfeeding with specialised support services had a longer duration, while those who discussed breastfeeding with physicians had shorter breastfeeding duration. Tchaconas et al (2018) also reported that very few women discussed their decision to breastfeed beyond infancy with their paediatric primary care provider and 38% of women reported that their provider was unsupportive of breastfeeding past the first year. This suggests that negative responses to continued breastfeeding have an impact on a woman's ability to breastfeed according to the recommended guidance.
The objective of this study was to understand negative experiences with health professionals for a cohort of women continuing to breastfeed their children between the ages of 1 to less than 2 years.
Methods
The research used a cross-sectional design and an online self-administered questionnaire to collect data from women at a single point in time. The questionnaire encompassed demographics and six open-ended text questions. Demographic details included the participant's country of residence, age, number of children, and ethnic and religious affiliation.
The open-ended questions delved into the reasons for initiating breastfeeding, the level of support from partners, family and peers, breastfeeding in public and experiences of negative responses from health professionals regarding their continued breastfeeding practices. The analysis presented in this article focuses on those who disclosed experiencing a negative response from a health professional.
To ensure the questionnaire's reliability, four representatives of breastfeeding women provided input on its wording and usability. Purpose sampling and snowballing techniques were employed for participant recruitment. Approval was sought from moderators of social media parenting support closed groups, and members were encouraged to further distribute the invitation.
The invitation included a link to participant information and an informed consent form. The study, conducted between June and May 2019, garnered 2299 responses from women who reported they had experienced a negative response to their breastfeeding from a health professional. Of these, 1951 women provided detailed free-text responses outlining their experiences (see Table 1).
| Total sample | Free text response | |
|---|---|---|
| Age of participants | ||
| ≤24 | 2 | 30 |
| 25–34 | 6 | 254 |
| 35–44 | 10 | 106 |
| ≥45 | 14 | 12 |
| No of children | ||
| 1 | 693 | 172 |
| 2 | 1147 | 175 |
| ≥3 | 469 | 469 |
| Ethnic group | ||
| White | 414 | 424 |
| Black | 14 | 12 |
| Asian | 71 | 67 |
| Mixed | 86 | 72 |
| Hispanic and Latino | 22 | 12 |
| Indigenous | 19 | 13 |
| Not stated | 11 | 7 |
| Residing continent | ||
| Europe | 1332 | 1315 |
| America | 743 | 402 |
| Asia | 40 | 40 |
| Australia and Oceania | 159 | 149 |
| Africa | 17 | 17 |
| Unknown | 15 | 15 |
| Religious group | ||
| Christian | 1046 | 837 |
| Buddhist | 13 | 12 |
| Jewish | 23 | 16 |
| Muslim | 40 | 37 |
| No religion | 1077 | 963 |
| Other | 58 | 50 |
| Not stated | 42 | 36 |
| Total | 2299 | 1951 |
Ethical approval for the study was obtained from the University of Derby's College of Health, Psychology and Social Care ethics committee. Each participant generated a unique code for secure data storage, allowing them to withdraw their data within 14 days of participation; however, no participants chose to exercise this option.
A content analysis formulated condensed, overarching category descriptions of the participant's experiences (Krippendorff, 2018). A coding manual was generated by the first researcher using breastfeeding literature. Categories identified included impact on treatment, judgement, advised to wean and stigmatised. Subsequently, the categories were discussed with the second researcher for agreement. To evaluate the internal validity of the coding manual, the entries of 100 participants were independently coded by both the first and second researchers.
A Kappa coefficient agreement in the decisions ranged from .693 to .964 for each five categories as either excellent or substantial (see Table 2). Throughout this procedure, the researchers convened after coding every 20 participant responses. Any discrepancies were documented and discussed, to fine-tune the coding categories. The coding manual was finalised and used by the first researcher to code all responses.
| Total sample | Free text response | |
|---|---|---|
| Impacting treatment | .832, <.001 | Excellent |
| Judgement | .693, <.001 | Substantial |
| Advised to wean | .964, .000 | Excellent |
| Stigmatised | .837, <.001 | Excellent |
| Other | .713, <.001 | Substantial |
Advised to wean
As outlined in Table 3, the largest proportion of responses (1227; 74%) were coded in the category Advised to wean. The advice women received did not align with the current recommendations. These experiences were received from multiple professionals:
‘A paediatrician yelled at me, stating that it has no nutritional value and I should put her on formula immediately’
‘My GP told me to stop feeding when I was pregnant because it's too hard on my body’
‘A nurse told me that my kidneys are in danger!’
| Category | N (%) |
|---|---|
|
Impact on treatment
|
90 (5) |
|
Judgement
|
297 (18) |
|
Advised to wean
|
1227 (74) |
|
Stigmatised
|
292 (17) |
Negative experiences also included advice that was not evidence based:
‘A health visitor told me it was like giving my son a McDonald's milkshake. Filling but no nutrients’
Another participant responded:
‘When my child had a cold virus a paediatrician said he had probably caught it from me through my breast milk’
Finally, there was advice deriving from personal experience:
‘My GP said, “It's probably time to stop, that's when I did”
Judgement
There were 297 (18%) responses coded in the category Judgement, indicating women experiencing blame from health professionals. Experiences included health professionals implying that the women were causing the child psychological harm:
‘Our paediatrician told me I was causing harm to my child by continuing to nurse whenever she demanded; she said that she has too much bond with me because of breastfeeding and being spoilt’
There were also experiences of health professionals implying breastfeeding was poor parenting:
‘The dentist and the doctor said that above a year was just for fun and it was a bad habit’
Another participant responded:
‘He told me that I was continuing for selfish reasons, for my desire’
Experiences also included the health professional indicating that the child's health or behaviour concern was due to breastfeeding:
‘Dietician telling me it's my fault my kid doesn't eat much’
Another participant responded:
‘Whatever the issue is, the breast milk must be the cause’
Stigmatised
There were 292 (17%) coded in the category Stigmatised. These experiences included when a health professional expressed shock or disgust. For example:
‘I broke my arm when my second was 1, and the emergency nurse went on about how disgusting it is’
There were also experiences where health professionals implied breastfeeding was for women who were stereotypical or unusual:
‘Going to get contraceptive. I mention breastfeeding in case it makes a difference. “Oh, still? Just give her cow's milk” – we're vegan so no. She said, “You're one of them hippy mums then that will still feed your 7 year old.” I stood up and walked out’
Another participant said:
‘A doctor told me, “You'll get weird looks soon” and that my baby would control my life if I didn't give it up. I ignored her. I felt belittled and ashamed’
There were also experiences of being questioned about how long the woman intended to continue:
‘My doctor asked, “How long are you planning on nursing her?” I felt judged but I looked him in the eye and answered “Until she self-weans, of course”’
Impact on treatment
A smaller percentage (5%) of total responses was coded in Impact on treatment. This indicates that, although less likely to occur, there were participants who were breastfeeding at this age who had been refused assessments, treatments or interventions because of their breastfeeding practice:
‘I had mastitis and needed antibiotics. The first doctor I saw was brilliant and said to come back if I needed a repeat prescription. For my repeat prescription, the medical professional I saw was reluctant to prescribe anything for me because she didn't think breastfeeding at “that age” was necessary and therefore the mastitis didn't need treatment’
Another participant responded:
‘My practice nurse also refused to offer a smear test as I am breastfeeding’
Another responded:
‘Male doctor giving up on diagnosis saying I wouldn't be able to take medicines to correct the problem anyway and ignoring my questions’
They had also been made to feel like their breastfeeding practice was an inconvenience to their healthcare:
‘They didn't try to give me medication and simply said I need to switch her to formula or cow's milk to take it. They don't even bother to find alternatives’
Discussion
The findings of this study indicate that the majority of the negative responses experienced from health professionals were when mothers were advised to wean (74%). There are studies that have examined health professionals' approaches to weaning. For example, Tedder (2015) highlighted that infant behaviours are commonly misinterpreted as breastfeeding problems, such as increased crying and frequent awakenings at night.
Morais et al (2017) suggest that paediatricians are the health professionals who most often recommend weaning on to infant formula. This could be because a large group in this study sample are from the USA, and the American Academy of Paediatrics only recently updated its guidance on continued breastfeeding to align with the WHO recommendations of 2 years and beyond (Meek and Noble, 2022).
The largest group are from Europe, aligning with a UK study (Jackson and Hallam, 2019) which discovered that, although child and family health services are effective at supporting breastfeeding in the postnatal period, beyond the infancy age of 1 year the focus shifts to rapid weaning. Therefore, more education is needed for health professionals internationally to ensure that they can provide evidence-based weaning advice, if requested by breastfeeding women, which reflect the WHO global recommendations.
The findings also revealed that women who experienced a negative response can feel judged (18%) and stigmatised (17%). Less frequent but most concerning were experiences conveyed where the health professional implied breastfeeding was an inconvenience to their treatment or withheld their treatment altogether (5%). Therefore, appropriate training is required for multiple health professionals to ensure care continues throughout a woman's breastfeeding duration. It reaffirms that women require evidence-based, sensitive, individualised and practical support with a respectful and mutual dialogue from health professionals to promote a positive breastfeeding experience (Blixt et al, 2019). Additionally, team-based, interprofessional approaches to breastfeeding support for mothers and their families have been proposed as an intervention to address institutional constraints, lack of co-ordination, and poor service delivery (Anstey et al, 2018).
These results analysed data provided by women who had experienced a negative response to their breastfeeding from a health professional. However, it did not collect data from those who did not have a negative response to breastfeeding or who may have had a positive breastfeeding experience. Therefore, it is only limited to highlighting negative practice. Additionally, this content analysis was able to examine the large volume of ‘free text’ qualitative data. This involved the condensation of the data using a coding manual of ‘categories’. The limitation of this approach is that the codes are condensed into broad descriptions. There are also distinct features within the codes which could not be measured in frequency. A future approach could explore how prevalent issues are within each category.
Finally, increasing breastfeeding initiation and duration would contribute to the global Sustainable Health Goals (www.globalgoals.org/goals) as it would contribute to ending preventable deaths of newborns and children with all countries aiming to reduce neonatal mortality. However, health inequalities and service provision are very different in each country. These findings represent western cultures and cannot fully provide a global context. Further research is required to reflect the needs of women in Asia and Africa.
Conclusion
These findings have emphasised the need for widespread training and education initiatives aimed at multiple health professionals to ensure that evidence-based, supportive, and non-judgmental care is delivered throughout a woman's breastfeeding journey. The implications of this research extend beyond individual interactions in healthcare, suggesting a need for a paradigm shift toward team-based, interprofessional approaches to breastfeeding support. Considering these findings, healthcare systems in Europe and the USA in particular, must prioritise comprehensive training programmes that align with current breastfeeding recommendations, fostering an environment where health professionals can support and empower women to continue breastfeeding.