Maternal perceptions of partner support during breastfeeding

Efforts to increase breastfeeding rates have been directed at all stages of a woman’s reproductive experience; during the preconception and prenatal periods, within 24 hours of delivery, and throughout the postpartum period in the hospital and at home. Since 1991 the Baby Friendly Hospital Initiative has been implemented in many hospitals and recommends: reduced use of infant formula; nurse assisted initiation of breastfeeding immediately after delivery; the hiring of lactation consultants for post-delivery assistance; and referrals to outside breastfeeding resources upon discharge [1]. None of these efforts seem to increase the duration of breastfeeding.

Breastfeeding duration is highly variable and falls well below the World Health Organization (WHO) and The United Nations Children’s Fund (UNICEF) recommendations of exclusive breastfeeding (no artificial milk substitutes or other fluids) for all infants to six months of age [2]. Most Canadian women try to breastfeed their infants and since 2003 breastfeeding initiation rates in Canada have remained stable at about 87% [3]. However, in 2007, only 23% of mothers reported exclusive breastfeeding for six months [4]. Twenty-five percent of women reported “not enough milk” as the most common reason for stopping breastfeeding. ‘Insufficient milk syndrome’ was recognized in the early 1980s and has persisted to current day as the primary reason women discontinue breastfeeding [5–7]. Although health care professionals offer timely support to breastfeeding women, the more constant presence and immediate support of the baby’s father, or mother’s partner offers opportunity to influence the maintenance and duration of breastfeeding.

Fathers and partners have been identified as being influential in mothers’ feeding decisions and the continuation of breastfeeding [8, 9]. If the mother feels that the father’s attitude towards breastfeeding is positive and supportive there is a greater likelihood that she will continue breastfeeding [10, 11]. Maternal perception of a negative attitude from their partner influences when a woman considers and decides to discontinue breastfeeding [11].

As part of a larger study looking at breastfeeding self-efficacy and medications used to increase milk supply [12], we asked women about their decisions to breastfeed; to identify breastfeeding supports and to describe their perceptions of their partners’ support and attitudes throughout their breastfeeding experience. It was hypothesized that those mothers reporting positive support from their partners would have higher confidence in breast milk production and higher breastfeeding self-efficacy.

Many of the mothers in our study reported that they had attended prenatal classes (76%, n = 56). Fifty-two women (68%) gave birth vaginally and 24 (n = 32%) had surgical deliveries. One third (n = 25) of our sample reported complications with their delivery. Previous breastfeeding experience was reported by 42% (n = 32) of women. Over half the women (58%, n = 44) did not use formula in hospital.

After partner support, the top three breastfeeding supports reported by women were maternal mother (65%, n = 49), friends (65%, n = 49), and physicians (61%, n = 46). Women felt supported by health care professionals at the hospital (92%, n = 70) and following discharge (96%, n = 73) with 77% (n = 59) seeking assistance for breastfeeding post-discharge. Valuable information was received from lactation consultants, nurses and family members. The most useful information women received for breastfeeding came from prenatal classes and health care professionals. The information addressed baby position and latch (25%, n = 15), supportive interaction (29%, n = 17), and advice on how to be patient and to persevere (17%, n = 10) through breastfeeding challenges.

Two categories for perceived maternal support emerged from the analysis of the open ended comments: ‘active/positive’ and ‘ambivalent/negative.’ Active/positive support (n = 38) was characterized by reports of emotional and functional support such as “he is the transporter, brings the baby to me” and “he is very encouraging.” Fifty five per cent of women perceived that their partner was “encouraging,” 23% said their partners thought breastfeeding was best or healthiest for the baby. However, 22% indicated that their partner felt indifferent or negatively about breastfeeding. Ambivalent/negative support (n = 32) was characterized by baby only related comments such as “Does not question me about it” or “good for baby and for the economy.” Frank negative comments about breastfeeding included it was “too time consuming,” “(he) feels that it is healthy for baby but it interferes with intimacy,” and that “(he) feels left out.”

In this study we demonstrated that partner support and encouragement were associated with maternal confidence and a perceived ability to breastfeed. Women who experienced positive and active support by their partners showed higher confidence in their ability to breastfeed than women with partners who were ambivalent or negative towards breastfeeding. Partner support was predictive of maternal confidence in breastfeeding regardless of any previous breastfeeding experience or the age of the infant.

In a mixed methods study examining fathers acting as breastfeeding allies, Pontes, Osorio and Alexandrino reported paternal attitudes towards breastfeeding including ambivalence, conflict, exclusion, and insecurity. The effect of these attitudes on maternal breastfeeding was not mentioned [27]. We found similar behaviors perceived by mothers that we termed ambivalent; “(he) is passive about it - goes along with my choices and what I wanted to try;” negative such as “inconvenienced” that adversely affected breastfeeding confidence. Mothers also perceived that partners felt left out and that breastfeeding interfered with intimacy. The effect of breastfeeding on intimacy is seldom mentioned in studies but could be a marker of stress in the re-establishment of sexual activity following childbirth and a topic for sensitive discussion between parents and with a health care professional.

We found that women breastfeeding at the time of the study reported positive perceived paternal support when compared to women who were not breastfeeding and who recalled ambivalent or negative support. Fathers may not recognize how influential active support is to instilling and sustaining the confidence mothers develop in breastfeeding. Active participation characterized by fathers assisting with “domestic chores, and presence during breastfeeding” were perceived by mothers as positive support - “he would sponge my breast before feeding, with warm water” and “he is the ‘transporter’ . . . brings the baby to me for feeding” and “he checked the (baby’s) latch.”

In contrast to earlier findings [10, 11, 28, 29], our study participants did not report that partners were instrumental in their decision to breastfeed. The majority of our sample were “always going to breastfeed,” often considered a predominant factor in infant feeding decisions. A study by Datta, Graham and Wellings found that although fathers were willing to support a mother’s decision to breastfeed, they did not feel that they were able to be a part of the decision making process [30]. This study found that fathers often felt left out of the decision making process and that their role was primarily one of providing supportive care to the mother [30]. However, fathers who were interviewed were conflicted as to how to provide support during specific breastfeeding challenges and were thus, more likely to support the mother’s decision to stop breastfeeding [30]. There is a growing body of literature suggesting that fathers should be included in both the breastfeeding decision making process and acquisition of positive, functional support behaviors postpartum [8, 27, 31–34]. Fathers will require information on the ways in which they can best support mothers in meeting breastfeeding challenges.

Timing of support is important in the initiation and maintenance of breastfeeding but also in the development of maternal confidence. Learning the skills of latching and positioning the baby early in the postpartum period is critical to establishing breastfeeding patterns and breast milk supply. Faced with challenges such as engorgement, latching difficulties, fatigue and perceived insufficient milk production, women without support and resources are likely to “give up” [6, 7, 10]. Partners who are present during this period could offer timely support and encouragement. Armed with information and rudimentary skills they could be engaged in targeted support activities. Timely partner intervention may be crucial to the continuance of breastfeeding.

Our results indicate that active support measures such as preparing baby and bringing beverages coupled with positive verbal phrases encouraged and sustained maternal confidence in breastfeeding. Health care professionals providing assistance in the prenatal and postpartum periods have an opportunity to help partners recognize that breastfeeding ‘is best for baby’ as well as the effect of encouraging words and deeds on mothers’ confidence and decision to continue breastfeeding. Strategies to actively support breastfeeding have a greater impact on sustaining mothers’ efforts. Verbal and nonverbal encouragement to mothers from fathers was reported by Rempel and Rempel to facilitate breastfeeding and was more likely to occur when fathers had increased knowledge about breastfeeding and used it to assist with breastfeeding challenges [33].

Involving fathers in breastfeeding will require increased efforts on the part of health care professionals to dispel the “exclusivity” of the mother/baby dyad. One of these efforts will be to offer information to partners so they can formulate knowledgeable solutions given problems they may witness. In 2006, Pisacane et al. found that teaching fathers (intervention group) about “fear of milk insufficiency, transitional lactation crisis, return to outside employment, and problems such as breast engorgement, mastitis, sore and inverted nipples, and breast refusal” and preventive and management techniques resulted in significant differences in successful lactation and increasing breastfeeding rates compared to the control group [11]. It should be noted that not all partners may be interested in this level of involvement. However, our results indicated that supportive partner interaction, advice on how to be patient and to persevere throughout breastfeeding challenges was the most useful for women.

We found that responses to the HHLS were indistinguishable between our two groups termed active/positive and ambivalent/negative. As one of the sub-scales measured maternal confidence and commitment, we would have expected that maternal perception of active/positive support from fathers may have positively affected maternal confidence and this could have differentiated the groups. It could be that the confidence in the ability to breastfeed as measured by the BSES is more affected by partner support than maternal perception of milk production or the maternal assessment of infant satiety.

Key breastfeeding supports were identified by participants. Interestingly, for our sample, health care professionals and mother/friends ranked almost equally but we note that their information bases may be different. Health care professionals offer evidence-based information whereas mothers/friends may have their information grounded in experience, folk lore, and television, internet or media sources. Prenatal class information was also identified as being helpful therefore relevant and accurate breastfeeding content should be maintained.

Our research focused on maternal perception of breastfeeding support not on the actions of partners. Consequently, we cannot conclude that partners were not providing instrumental, emotional, or other forms of support, only maternal perception of that support. Information could be provided to fathers to attend to how mothers wish to be supported during the prenatal and postpartum period and give examples of active and positive supportive behaviors.

Mothers reporting positive support from their partners had higher confidence in breast milk production and higher breastfeeding self-efficacy as measured by the BSES. Our results concur with previous studies that partners can influence a woman’s confidence in breastfeeding [11, 28, 32]. More specifically, those fathers who actively support and encourage women by helping position the baby and bringing snacks and diapering, are highly influential in a mother’s perceptions of confidence in breastfeeding. It is important that health care professionals appreciate the influence positive and active partner support has upon maternal feelings of confidence in breastfeeding and offer partners tips on common support strategies. In both prenatal classes and during postpartum stay in hospital as well as postpartum visits, health professionals can invite partners to become active learners and highlight supportive functions that are known to be meaningful to mothers. For some, learning solutions to common breastfeeding challenges may offer an opportunity for mothers to have an in-house resource. Future research could address knowledge gaps partners may have, the effect of breastfeeding on sexual intimacy for both parents and explore the disconnectedness partners have reported.

CAM is an Associate Professor with the Faculty of Nursing, University of Calgary. AH is a former student with the Faculty of Nursing, University of Calgary. SM is a post doctoral fellow at the Child Development Centre, Alberta Children’s Hospital. ST is a Professor, Departments of Pediatrics and Community Health Sciences, Faculty of Medicine, University of Calgary Health Scholar, Alberta Heritage Foundation for Medical Research Scientific Director, Child Development Centre Alberta Children’s Hospital.