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Breast-feeding has many known health benefits for both mother and child, and therefore the American Academy of Pediatrics recommends exclusive breast-feeding for the first 6 months of life and continuation of some breast milk consumption up to 1 year old(Reference Gartner, Morton and Lawrence1). These recommendations are consistent with the WHO, which recommends exclusive breast-feeding for 6 months and continuation of breast-feeding supplemented with appropriate food for up to 2 years or beyond if desired by mother and child(2). For infants born in the USA between 2003 and 2006, breast-feeding was initiated for 73·4 %, continued until 6 months for 41·7 % of infants, and until 12 months for 21·0 %(3). These figures remain below the target levels for the Healthy People 2020 goals of 50 % rate at 6 months(4, 5). In contrast, 79 % of 12-month-old infants around the world are breast-fed(Reference James and Lessen6). Although the USA is approaching the 2020 goals, these goals are significantly lower than global rates and the ideal of nearly 100 % breast-feeding for almost all infants(4, 5, 7). In the greater Boston area (state of Massachusetts) where the present study was conducted, 77 % infants ever received at least some breast-feeding, with 46 % continuing to be breast-fed at 6 months and 20 % at 12 months(8). The initiation rate was higher among non-US born mothers in this region (92·5 % v. 77·1 % in US-born mothers), and those with some college education exceeded 80 % breast-feeding initiation rate while among those without the rate was only 71 %(9).
Several studies have shown that the father plays an influential role in helping the mother determine which type of infant feeding will be used(Reference Arora, McJunkin and Wehrer10, Reference Freed, Fraley and Schanler11). In particular, fathers’ beliefs about breast-feeding may play a key role in the final decision of feeding method(Reference Freed, Fraley and Schanler11, Reference Scott, Binns and Oddy12). Social support, especially from infants’ fathers, has been shown to be beneficial for the initiation and duration of breast-feeding(Reference Ekstrom, Widstrom and Nissen13, Reference Souza, Souza and Tocantins14). Lack of psychosocial support reduces the likelihood that a woman will breast-feed her child(Reference Matich and Sims15). In a Finnish study of first-time mothers, mothers cited fathers as the most important member of her breast-feeding support team(Reference Tarkka, Paunonen and Laippala16).
Despite the recognized role of fathers in breast-feeding, little is known about the specific support needed and desired by breast-feeding mothers from fathers(Reference Sherriff, Hall and Pickin17, Reference Susin and Giugliani18). The aim of the present study was to examine mothers’ experience of support received from fathers for breast-feeding.
Methods
Sample/population
The study population was women with recent breast-feeding experience in urban and suburban areas around a major city in the north-eastern USA. In early 2010 a convenience sample of women was recruited from a paediatrician's office, parenting groups and a university. Eligible mothers were those who were living with the biological father of the child and whose first child was 1 year of age or less at the time of the study, born full-term (37–42 weeks’ gestation) and not having a low birth weight (≥2500 g). These women must also have exclusively breast-fed the child for at least one consecutive month since birth, and if breast-feeding had ceased, the time since discontinuation must have been no more than 3 months. Exclusive breast-feeding was defined as feeding the infant only breast milk and no formula supplementation. Exclusive breast-feeding included both expressed milk in a bottle and milk directly from the breast.
Informed consent was obtained prior to the voluntary participation in the study. The institutional review boards at Simmons College, Boston, MA and Beverly Hospital, Beverly, MA approved the study.
Data collection
We conducted semi-structured qualitative interviews with open- and closed-ended questions related to the type of support mothers received from fathers for breast-feeding (Table 1). Interview questions were pilot tested with women who were currently or had previously breast-fed. Questions included the mother's opinion regarding the role of the father in the breast-feeding process, preparation of the father for breast-feeding, and if there was anything absent in the father's support for breast-feeding. The two researchers met periodically throughout the interview process to ensure that similar styles were used to conduct all interviews. Interviews were reviewed as data were collected and recruitment continued until thematic saturation was achieved and no new themes emerged from the interviews. Saturation was reached after the completion of nineteen interviews.
Interview questions
Analysis
Every interview was transcribed verbatim from the recording. After the interviews were transcribed, two investigators (L.E.N. and A.C.S.) read the transcripts independently and identified common themes and categories present in the interviews using content analysis. They then re-read the transcripts together, marking the presence of different themes and developed categories. The researchers continued to meet during the analysis of the transcripts to discuss potential overlapping themes and ambiguous statements in the transcripts. Re-evaluation of the themes took place as necessary. The investigators independently coded each transcript and put common themes into appropriate categories. Consensus was reached and there was high inter-rater agreement between the two investigators, with a score of 83 %.
Results
Nineteen face-to-face interviews with married women were conducted. The mean maternal age was 30 years and the mean infant age was 7 months (Table 2). Most of the participants were from suburban settings, had some higher education and were breast-feeding at the time of the interview. While the majority of mothers interviewed were white, 26 % were of other races.
Demographic data of participants: women (n 19) from a metropolitan area in the north-eastern USA
*Mixed race.
Ten thematic categories emerged from the analysis (Table 3). They ranged from fathers’ involvement in the decision to breast-feed to emotional and practical support provided by fathers, education for fathers and the mothers’ perception on fathers’ feelings in the process.
Themes that emerged from the interviews with mothers
Theme 1: Fathers supported the decision to breast-feed
Several mothers described the breast-feeding decision as a mutual decision between the mother and father. Many of these mothers or their partners were breast-fed when they were infants and viewed breast-feeding as something that was important to them:
We did a lot of research about breast-feeding; kind of know the health benefits of it. I was breast-fed, he was breast-fed, and we knew that we really wanted to do that.
Even if it was not a mutual decision, the fathers were still supportive of the mothers’ desire to breast-feed. Some fathers left the ultimate feeding decision up to mothers since breast-feeding mothers carry more of the responsibility of feeding the infant than fathers:
[My husband] felt like [the breast-feeding decision] was up to me since I'd be the one taking on the burden of doing it.
Several mothers viewed breast-feeding as an economical option that was more affordable than formula, which helped them form their feeding decision.
Theme 2: Multifaceted approach to breast-feeding preparation was helpful
Mothers prepared for breast-feeding in a variety of ways, with many women reading books, attending classes and talking to other women. In some cases, mothers reported fathers were very involved in the breast-feeding preparation process and in others fathers left the preparation primarily up to the mothers.
Breast-feeding classes as a form of preparation
Taking a breast-feeding class was a popular method of preparation. For the majority of mothers who participated in a breast-feeding class, fathers joined them in the class. Mothers cited benefits for fathers’ attendance at the breast-feeding classes, including teaching fathers some of the basics of breast-feeding so they could assist mothers when they encountered difficulties. Mothers also felt that classes helped fathers become more comfortable with breast-feeding:
… he was in the class, he got familiar with [breast-feeding] … it's always helpful to have a second set of ears to listen to things.
Breast-feeding preparation for husbands
Mothers reported that their husbands had variable involvement in breast-feeding preparation. While some husbands were very involved in the preparation process, such as attending classes, others had minimal preparation. One participant stated that her husband was not really involved in the preparation, in part because she did not ask him to be and in part because
I was trying to figure it out on my own. It was really about me, it really had nothing to do with him personally.
For fathers who were not involved in preparation, mothers felt there was only so much preparation fathers could actually do before the baby arrived.
Fathers benefited from education
In contrast, some mothers felt their partners really benefited from breast-feeding preparation and education. A common feeling was that much of the woman's own preparation ‘went out the window’ right after the baby was delivered. One mother discussed how since her husband had become educated about breast-feeding, he was the one who remembered the information and was able to help her apply that knowledge right after delivery. Another mother explained that her husband had an equal knowledge of breast-feeding, which was helpful:
… so that he wasn't [worried] either about things that seemed unusual or long or hard or anything like that.
Theme 3: Mothers perceived fathers benefited from lactation consultant support
One form of support after the birth that was seen as helpful for both mothers and fathers was that of a lactation consultant. For some, simply having the husband present in the room to hear what the lactation consultant said and being able to mentally back up the mother at home was seen as being very helpful. For others the lactation consultant played an active role in showing the father ways he can support the mother. Referring to the lactation consultant, one mother stated:
I think it made him feel good to have seen somebody else sit with me and coach me through [breast-feeding] and then he would kind of do the same thing.
Theme 4: Fathers felt helpless and disconnected from breast-feeding
According to some mothers, fathers experienced a variety of feelings related to breast-feeding. The most common feeling mentioned was one of helplessness. At times there was only so much a father could do to help his partner with breast-feeding difficulties:
… he's verbalized to me that he feels sort of helpless in it, that he's like I can't do anything for you.
Other mothers described their partners as feeling disappointed that they could not be as involved in the feeding process as they would have liked. As one mother stated, her husband was not prepared for the fact that he could not become involved as much as he wanted, which then led to
a little bit of jealousy and a little bit of a let down that the baby's 100 % relying on me and he's just making the money to support all of this.
Theme 5: Mothers benefited from fathers’ emotional support
Many women cited emotional support as being one of the key ways that their husbands supported breast-feeding. A few women indicated that it was helpful not only to have their husbands support the decision to breast-feed, but also to support the decision to use formula if need be:
… for me it was very helpful to know that he supported me and that he wanted me to do it, but also that if it didn't work that he was okay with that too. It was really helpful not to feel like he would be upset if it didn't work out.
Women also indicated that their husbands provided emotional support by reminding them that breast-feeding was a good thing for the child. One woman reported that her husband would tell her often that breast-feeding was a beautiful thing and it was a wonderful thing that she was giving to their baby.
Encouragement for breast-feeding
One way that fathers provided emotional support was through encouragement for breast-feeding:
The thing he did right was support me when I felt like I couldn't do it, not didn't want to, but couldn't do it anymore.
One woman indicated that her husband was especially encouraging shortly after the baby was born. The couple received samples of formula in the mail. The mother was tempted to use the formula, but the husband encouraged her not to and to continue with exclusive breast-feeding.
Father as a partner in breast-feeding
Several women also indicated that their husband was a partner in breast-feeding. These women said that it was helpful to have similar thoughts and views about breast-feeding:
I think the key is just to get on the same page with it and once you're on the same page, understand what it is and understand this is good.
Theme 6: Fathers provided physical support to mothers
Husbands provided many types of physical support to breast-feeding mothers, including helping their wives get set up for breast-feeding and physically bringing the baby to the mother to nurse. Men were involved in physically helping the baby to nurse by assisting the mother in finding a comfortable position for breast-feeding, stimulating the baby to stay awake during nursing, and helping the mother to move the baby when it was time to switch positions or switch to the other breast. When husbands were not physically helping their wives to nurse, they provided physical support by getting mothers necessary supplies for breast-feeding including water and pillows. Fathers also attended to other household tasks so that the mothers could nurse without being worried that something else around the house was not getting done:
If I had to empty the dishwasher or something like that and I had to nurse, he'd be like go ahead [and nurse] and I'll do the rest, don't worry.
Fathers also provided physical support outside of home by assisting mothers when breast-feeding in public:
Quite a few times since [the baby has] been born, we've been at parties or picnics or something and if we were in a situation where I couldn't breast-feed openly … he would come with me so that I wasn't … nursing by myself.
Another mother reported that her husband would assist breast-feeding in public by taking out the nursing cloth and helping her to get set up to breast-feed.
Theme 7: Mothers perceived fathers enjoyed being involved in the feeding process
Mothers reported that their husbands were involved in many aspects of feeding including feeding their babies’ pumped breast milk. Women stated their husbands would help to feed the baby bottles during feedings at night and when mothers had other commitments that limited breast-feeding. Mothers perceived fathers enjoyed having an active role in feeding by giving their babies bottles, solid foods and ‘sippy’ cups. One woman suggested that her husband felt much more involved in the feeding process when feeding expanded beyond just breast-feeding:
We started doing [solid] food at six months and I noticed that there was bit of a change where daddy was involved with feeding and that was exciting.
Themes 8: Challenges in breast-feeding
There was a wide range of difficulties encountered by the mothers in this sample. Many of the mothers mentioned that tiredness and exhaustion from waking up multiple times during the night to feed their child made it challenging. For some the tiredness and associated frustration made it more difficult for the husband to support the mother; for others the tiredness of both parents made their relationship more difficult. In talking about how hard it is to nurse at night, one mother stated:
it's challenging and I think inevitably like resentment sets in sometimes when you're exhausted and getting up two or three times a night to feed the baby.
A few mothers mentioned the difficulty with breast-feeding desexualizing one's breasts. While these women did not encounter such feelings with their husbands, they commented on other women whose partners struggled with this idea. One woman knew some women who don't want to breast-feed in front of their husbands because they are afraid that breast-feeding will desexualize their breasts and they will lose intimacy.
Breast-feeding is much harder at the beginning than expected
The majority of mothers stated that breast-feeding was very difficult in the beginning and support of the husband at this point was essential to the continuation of breast-feeding:
… but the first two days I don't know how I would have done it without somebody else there. I think it would have been really hard.
Additional difficulties due to Caesarean section
A number of women had Caesarean sections. A few of these women commented that the Caesarean section surgery was unexpected and increased their need for support:
I had a C-section … but if [my husband] hadn't been there to … support me, I don't know if I [could have breast-fed] … you go through this major surgery and you're on all these meds and anesthesia … you're just not there. So what would [I] have done without that support, the lactation consultant and [my] other half, [my] husband.
The addition of recovering from the Caesarean section and being a new mother just starting to breast-feed made mothers rely on their husbands that much more for support.
Situations that require additional support
There were numerous situations where women felt that they needed additional support from their partners, such as during periods of sickness, transition back to work, changes in supply, or other frustrations. Simply being a first-time mother was cited as requiring extra support compared with second- and third-time mothers. One mother described her experience with mastitis as a time when she felt very insecure and vulnerable, as she was home alone with her infant while her husband was at work. During this time she felt
a little bit depressed about the whole thing. So I think it made it harder for him to find ways to make me happy and … remind me that [breast-feeding] is a good thing.
Men uncomfortable with breast-feeding
A few women described their partners as being somewhat uncomfortable with breast-feeding. Women said that their husbands were anxious about the length of breast-feeding as well as nursing in public:
… our only conflict is over the breast-feeding in public stuff. He really just kind of cringes at that.
Breast-feeding-related conflicts between mothers and fathers
Breast-feeding was the source for a variety of conflicts between mothers and fathers. Conflicts ranged from fathers not acknowledging the amount of work that goes into breast-feeding to fathers not properly handling the breast milk or suggesting that the mother pump or use formula:
There was a point … around 3 or 4 months where [my husband] would suggest that we supplement with formula and I remember taking offense to that in a big way … there were moments where I was like you don't understand. You just have no idea.
Weaning as a particular challenge
The decision to start weaning was especially difficult for some mothers, especially for mothers who returned to work and had difficulties with keeping up with meeting the demands of work and exclusive breast-feeding. This time of weaning was frequently seen as a stressful time for both parents and one that required more support:
… it was the support for weaning that was really hard, not the support for [breast-feeding] … it definitely causes a lot of stress for both mother and father … because its just stressful for the moms and then the dads because they don't get it.
Theme 9: Women need emotional support to make breast-feeding successful
Women identified the major factor in making breast-feeding successful was emotional support, mainly encouragement. Women said that encouragement was especially important at the beginning when breast-feeding first began and the process was new and difficult. Women also needed affirmation that breast-feeding can be hard sometimes and support from their husbands to continue breast-feeding during difficult periods:
When you got your partner saying I know it's hard, but we can do this and let's try this and what can I do, I think that's huge. I think that's a big support that all breast-feeding moms need but they don't always get.
It is also helpful for mothers when their husbands are supportive of breast-feeding as the best choice for the family and the baby. Women reported that they need their husbands to be a ‘cheerleader’ or a ‘cheer coach’ to help support and encourage them through breast-feeding.
Theme 10: Fathers would benefit from more outside support for breast-feeding
Mothers can obtain support for breast-feeding from other women, lactation consultants and mothers’ groups, but the support for fathers is more limited. Mothers said that their husbands would benefit from having outside support from other fathers regarding fatherhood and breast-feeding. Some mothers identified that their husbands already utilized informal support from male friends with children:
He has a good friend of his who has a baby who's a little bit older and so he talked a lot with him [the friend] about general kinds of adjustment issues in terms of having a baby and about breast-feeding and what their experience is like and that seemed to have been helpful.
For mothers whose husbands did not have this outside support, many felt that it would be useful:
I think if he had someone who was going through the same thing it would probably be helpful. We're … the first friends in our group to have a baby.
Some mothers felt that professional support, education, talking with veteran dads and having a safe space for fathers to express themselves were beneficial.
Discussion
Our results show that mothers perceived fathers play an important role in the breast-feeding process by emotionally and physically supporting the mother and are a critical component to breast-feeding success. Furthermore, many mothers commented that fathers’ support was especially crucial when they encountered feeding challenges. However, mothers believed that fathers may benefit from more preparation and support before and during the breast-feeding period.
Previous studies have shown that paternal support is important for breast-feeding, but few recent studies have examined the specific type of paternal support women need(Reference Sherriff, Hall and Pickin17, Reference Susin and Giugliani18) that may be important in sustaining breast-feeding. We examined the exact type of support that women received from fathers and what they felt they need for breast-feeding success. The identification of particular practices fathers can perform to help mothers with breast-feeding, including sitting with the mother while breast-feeding, recognizing the amount of work breast-feeding requires of the mother and bringing the baby to the mother, makes the findings of our study unique. At the same time, our results affirm previous research that found fathers may provide support to breast-feeding mothers by relating information learned in the intervention to breast-feeding mothers(Reference Susin, Giugliani and Kummer19). In another study, fathers reported providing support to the mother and child in multiple ways such as affirming the woman's decision to breast-feed and showing physical support to the mother and child in between or during feedings(Reference Schmidt and Sigman-Grant20). Similarly, in our study we found that physical and emotional support by fathers is important for breast-feeding success. Several of the mothers in our study reported encountering unexpected challenges related to breast-feeding. These women cited their husbands being a positive influence during these difficult periods to help them persevere and continue breast-feeding. This is in agreement with a study that found a significant relationship between a father's ‘positive’ or ‘very positive’ attitude and the ability to cope with breast-feeding(Reference Tarkka, Paunonen and Laippala16). Our study affirms the influential role of fathers in breast-feeding and also shows specifically how fathers may tailor their support to promote breast-feeding continuation.
The narrow inclusion criteria of our study allowed us to avoid the influence of single mothers, multiple births, previous breast-feeding experience, medical factors that may alter breast-feeding and situations in which the biological father is not involved. The open-ended, in-depth interviews allowed for reporting more details of their personal experiences, which cannot be captured with a quantitative instrument.
Women in our study were from one major metropolitan area in the north-east USA; therefore, women living in other parts of the USA or more rural areas may prefer different paternal support and we were not able to capture that. Another limitation is the socially and economically homogeneous sample. Although 25 % of the participants were non-Caucasian women, they all had at least some college education and were similar to the Caucasian participants in other demographics; therefore this may limit the application of the present results to other populations. Culture has a major influence on breast-feeding practice; although the non-Caucasian participants in our sample may have different perceptions of the father's role, their insight may widen the scope of how fathers may be helpful to mothers on breast-feeding. Our data were obtained from mothers, representing their perceptions of the fathers’ behaviour and feelings. We do not have information from fathers, which would add a different dimension of insight to their role in supporting breast-feeding. Future research from the father's perspective is needed. Nevertheless, because mothers are the benefactors of fathers’ support, their perception of what is helpful is of primary relevance.
The results of our study contribute important knowledge to the areas of lactation, public health, nutrition, paediatrics and health education. Several previous studies have indicated fathers have inadequate knowledge about breast-feeding and would benefit from being included in more prenatal education(Reference Deave and Johnson21–Reference Tohotoa, Maycock and Hauck23). In the USA, prevalence of breast-feeding for 6 months and beyond is well below target levels and health-care providers play a critical role in promoting and supporting breast-feeding. Knowing the type of support fathers can provide for breast-feeding, and what fathers need in order to support mothers during breast-feeding, may inform public health education about breast-feeding. Since fathers have such a prominent role in breast-feeding support, health-care providers may incorporate the findings from our study when working with couples in the pre- and postnatal periods to help encourage increased breast-feeding initiation and duration. This may be accomplished by clinicians encouraging fathers to attend and be present at clinic visits, participation in breast-feeding classes and lactation consultations. To help increase breast-feeding duration rates in the USA health-care providers need to work together to help fathers realize their role and influence in breast-feeding. Because data on the needs of fathers are sparse, additional studies are needed to identify factors that affect fathers’ motivation and the information that they need to support mothers. In addition, workplace-related policy such as ample paternity leave and flexible work schedules would be beneficial for fathers to support mothers to sustain breast-feeding.
In conclusion, our study identified specific types of support mothers need for breast-feeding continuation, including encouragement during breast-feeding difficulties and reinforcement of the decision to breast-feed.
Acknowledgements
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. No conflicts of interest exist. The work was conducted when L.E.N. and A.C.S. were graduate students at Simmons College. L.E.N. and A.C.S. devised the interview tool, conducted the interviews, and reviewed and analysed the data. T.T.F. reviewed the interview tool, transcripts and manuscript, and provided research guidance. The authors wish to thank the women who participated in the study, as well as the nutrition department at Simmons College for all of their support.
