Although I did not ask participants directly about autonomy, most of the women in this study considered that they had control over their decisions to exclusively breastfeed their
babies. Statements within the interviews such as “He tells me not to do formula feeding but it is up to you” (Naomi, 2013), “I want to do it [breastfeeding] with her” (Maya, 2013) and “I was open… to look[ing] into other options” (Nicole, 2014) indicate that the women who
participated in this current research had autonomy over their breastfeeding decisions. The following section focuses upon the spontaneous talk from research participants about control over and constraints to exclusive breastfeeding behaviour that occurred in the interviews.
Julia (a lecturer) who breastfed exclusively her baby for the full six months spoke about her autonomy to make the decision to breastfeed exclusively for six months. She talked about the influential factors on her intention to breastfeed such as her knowledge and her experience of successful breastfeeding:
I don’t know, I probably just made my own decision on that. I definitely think it’s the best thing that you can do for them. I don’t know if there’s anything in particular that made me think that. Probably advice and information from everywhere. I don’t know if I could say anything in particular other than that I know it’s good, and I know it to be good from previous experience is probably the best. (Julia, February 2014)
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Similarly, Victoria who had completed a bachelor degree and breastfed her baby exclusively for more than five months spoke about the adequate availability of breastfeeding knowledge and information:
The only thing is you can’t really ignore all the information that is everywhere about ... but I think the middle-class intelligent people that it’s possibly not aimed at, can’t ignore all the information that’s being cited about how good it is for them. (Victoria, February 2014)
Victoria comment also indicates that the educated and socially advantaged mothers consume this information more than the targeted audiences do. Ella, exclusively breastfed her baby for the whole six months while still breastfeeding her four years old son. She also claimed that it was her decision to exclusively breastfed her baby.
I guess having my husband’s support is really good but really it’s just my decision that I wanted to breastfeed him so yeah. (Ella, June 2014)
Ella’s comment has shown that having good social support is effective for initiating and sustaining breastfeeding, however, the importance of the mother’s control over her decision to breastfeed cannot be ignored.
Kate who breastfed her baby exclusively for the full six months also talked about her antenatal intention to breastfeed exclusively and her autonomy to turn her intention to action. I don’t know if it [breastfeeding information and advice during pregnancy] really influenced my decision to breastfeed because I was already planning on breastfeeding. Yeah – yeah – yeah but it kind of influenced me to want to do it longer. (Kate, January 2014)
Kate did not consider any information or advice as influential on her decision to initiate breastfeeding. However, Kate spoke about the influence of informational support on the
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maintenance of her six months exclusive breastfeeding behaviour. Similarly, Jocelyn talked about her autonomy to breastfeed her baby exclusively.
Well, my mother-in-law and my sister-in -law keep asking me if she’s on formula – drinking from a bottle yet, and I get very annoyed when I get asked that question because I don’t want to use formula and I don’t want to go to a bottle. So they keep saying oh is she on formula yet – is she on a bottle yet? .... and I’m like no she’s not. (Jocelyn, March 2014)
Jocelyn’s significant others encouraged her to formula feed, however, she sustained her
exclusive breastfeeding practice which shows that Jocelyn had control over her decision to not formula or bottle feed her baby.
Brianna, who exclusively breastfed her baby for more than five months talked about autonomy over her decision to exclusive breastfeed despite all of the lactation problems that she experienced over an extended period including having formula suggested as an alternative:
Every time I would latch the baby on I actually couldn’t help but I was crying. And I think he [her husband] got really upset to see that I was in pain so he would kind of be suggesting maybe we [Brianna & her husband] should give up, maybe we should try a formula, because obviously he thought that it was too painful. So even though I didn’t listen to him, so it doesn’t matter, but I would have preferred that he was like let’s keep going with this, we can sort it out, we’ll find a solution with the breastfeeding… (Brianna, February 2014)
According to Swanson and power (2005), perceived behavioural control can be measured by the level of autonomy a mother has over her breastfeeding behaviour. In a study of prolonged duration of breastfeeding, Rempel (2004) used the theory of planned behaviour to explain the intended and actual duration of breastfeeding. Perceived behavioural control was an important factor for predicting antenatal intention to prolong breastfeeding duration. There was a significant positive relationship between the amount of control that the mother felt over her breastfeeding and actual duration of breastfeeding. In comparison, a lack of control over
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breastfeeding was the most influential factor for weaning before intended duration (Rempel, 2004).
Lucy was another participant who had a lot of breastfeeding issues during the first few weeks after birth such as sore nipples and breast pain. Despite these challenges Lucy sustained exclusive breastfeeding for the full six months. She spoke about how much health professionals and health messages around breastfeeding encourage mothers to breastfeed, which she appreciated. However, Lucy stated that she was the main person who made the decision to breastfeed and that she had complete control over her choice.
I guess it’s more society as well - that breast is best and to do that. I definitely can feel that that is what people push you to sort of do and all that. And my midwives – yeah both of them have been yeah that’s the way to go and things like that which is good. I think they should be telling you that. But no I guess at the end of the day I was always dead set I was going to breastfeed and I don’t think it would have altered what influence was going on, otherwise that was my choice, I was going to be breastfeeding regardless and the fact that I knew my mum had done it with all four of us kids, my sister –. (Lucy, April 2014)
Mila originally had an antenatal intention to breastfeed exclusively for six months. She was the only participant in this research who gave up breastfeeding after one week postpartum due to sore nipples, and started formula feeding her baby. Mila spoke about the social barriers to breastfeeding particularly breastfeeding in public.
I think initially I wanted to breastfeed because it’s best, it’s easier isn’t it? You don’t have to worry about buying stuff and making it up and taking the stuff out with you, and it’s all natural and all that. It’s good stuff. I was actually – to be honest – a little bit apprehensive about breastfeeding in public ‘cos I’ve got quite big boobs. I’ve got a sling, though, which was useful, and I thought if it’s working I’ll just work out a way of doing it. But I was slightly sort of nervous about it, ‘cos there’s no subtle way of getting you out, if you know what I mean. But I think the things that made me want to do it was the fact that it is natural and it’s just the best for baby if you can do it. (Mila, October 2013)
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Mila was the only participant to mention that she worried about how she would manage her intention to breastfeed exclusively for six months without breastfeeding in public. Mila was also the only participant in this study that had immigrated to New Zealand from the UK one year before her interview. Her opinion about breastfeeding in public may refer to her cultural background, since none of the New Zealand born participants mentioned breastfeeding in public as a barrier. However, research has shown that embarrassment or stigma associated with breastfeeding in public, or even in front of family members, is a common social barrier for new mothers who may find it difficult to overcome this obstacle (Bonia et al., 2013; Bueno-Gutierrez & Chantry, 2015; Shortt, McGorrian, & Kelleher, 2013; Ware, Webb, & Levy, 2014). Therefore, there is a necessity the normalisation of breastfeeding in public to be implemented alongside the education of health professionals as
well as the pregnant women’s significant others around the current knowledge and effective
support for exclusive breastfeeding.
Overcoming unforeseen barriers to breastfeeding, such as sore nipples, is difficult for many new mothers. However, in this research most participants had the ability to overcome barriers to breastfeeding and had complete control over their decision to breastfeed exclusively. Even when close family members offered formula as an alternative, when they faced breastfeeding issues such as insufficient breast milk, sore nipples and breast pain, they strongly rejected their offers. Factors that encourage mothers to choose breastfeeding include a high level of education, good social supports, breastfeeding perceived as a cultural norm by the mother’s significant others as well as the society in which she lives (Battersby, 2010). The findings of the current research are similar to the results of other studies that have applied the theory of planned behaviour to explore the relationship between antenatal
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intention and breastfeeding behaviours (Behera & Kumar, 2015; Giles et al., 2007; Ismail et al., 2013; Lawton et al., 2012; McMillan et al., 2009; Oosterhoff et al., 2014; Swanson & Power, 2005; Walsh, Kearney, & Dennis, 2015). While some of these studies found one factor to be more important the other factors, this research has identified that behavioural beliefs, subjective norms and perceived behavioural control are equally important influences on intentional exclusive breastfeeding practices.
In addition, from a social psychological point of view self-identity is also an important part of an intentional action (Carfora, Caso, Sparks, & Conner, 2017; Carfora, Caso, &
Conner, 2016; Dean, Raats, & Shepherd, 2012). Carfora et al. (2017) considered that the
variables within the theory of planned behaviour, relating to behavioural beliefs, subjective norms, and perceived behavioural control, are not adequate for the prediction of the performance of an intentional behaviour. They concluded that self-identity is a major part of
an individual’s self-concept which predicts the intention and/or the performance of a behaviour (Carfora et al., 2017). The following section will discuss how self-identity can be added to the theory of planned behaviour as an additional factor for predicting antenatal intention, initiation and duration of exclusive breastfeeding.