1. Faculty of Medicine and Health Sciences Feeding Baby: Pilot interviews with new mothers about infant feeding Gillian Hawkes and Angela Cassidy

2. Introduction Infant feeding, in particular breastfeeding, is one of the most debated (and contested) areas of maternal and neonatal health care. Much research and many public health campaigns have focused on increasing breastfeeding initiation and duration rates. Despite this rates in the UK remain below the government’s and WHO’s targets. Infant feeding operates as a ‘signal’ issue: it determines philosophies of parenting and one’s capacities as a mother.

3. Infant feeding, advice and expertise Mothers have been shown to be sensitive and vigilant to criticism in their interactions with health professionals. Interactions between parents and health professionals have been described as ‘encounters ... drenched with implicit moral judgements, claims and obligations (Plumridge et al., 2008) Resistance to public health messages is common and individuals have adapted and transformed ‘advice’ to fit their own concept of what was appropriate for them (Lupton and Chapman, 1995) There has been a focus on early infant feeding but less so on weaning. The messages that are given out often focus on developing healthy eating habits to avoid childhood obesity.

5. Results Advice Mothers frequently spoke about the sources of advice they accessed and how the different sources of advice made them feel. I think it depends a lot on which person you talk to and which health visitor you talk to because I talked to a couple of them and they said it was normal and then the third one talked to she suggested that I switch formulas and there was nothing wrong with switching formulas. (Mother, first child, age 32)

6. Results Advice (cont) Mothers felt that they were expected to find out about formula feeding and weaning for themselves, as there was a lack of ‘official’ advice available. This often left mothers feeling anxious and confused. It would have been useful to know when to increase the dose because even though the packet says well it could be between 4 and 6 kilos ... the health visitors don’t really tend to give you – if I wanted I would look on the internet ... and we couldn’t find anything on the internet. (Mother, first child, age 28)

7. Results Advice (cont) Mothers also commented on the differences between the amount of support and advice available to them when starting breastfeeding compared to the advice available to them with regards to weaning. It was very poor ... I remembered that I asked them in the class and in the end they always mentioned ‘the book’. They replied but with little information. I was not happy with the information you receive. I asked my sisters, family, friends. It’s the opposite with breastfeeding in this case I was more than happy. (Mother, two children, age 39)

8. Results Advice (cont) However, mothers who had breastfed felt positive about the advice and support that they received from midwives and health visitors. Since the moment she was born in hospital, I spent one night because the baby didn’t eat well or take the breast properly, they helped a lot. After two weeks, the midwife came at home to make sure that the baby grows correctly, she receives enough milk. (Mother, two children, age 39)

9. Results Advice (cont) Mothers turned to other mothers for advice and support and felt these to be positive experiences. Family members, such as sisters and mothers, were a trusted source of advice. There was little fear of being judged or found wanting by asking peers and family for advice and help. When I was pregnant I looked for a lot on the internet. I asked the midwife and my sisters who live in Spain. They have had children, how they are doing things, if they eat this or that. At the beginning when the baby was born my sister came here and I think if it hadn’t been for her help and her, I would have given up. It [breastfeeding] was very painful. (Mother, one child, age 39)

10. Results Advice (cont) Conflicting advice often left mothers feeling confused but it also made them question the trustworthiness of ‘official’ advice and this led some mothers to rely on ‘common sense’ and trust their own instincts. This was particularly the case for mothers with roots in either France of Spain, as they could see that advice shifts between different countries. I’m not sure really, I mean, I suppose it is difficult because every baby is different so they would have to give very general advice and then you just follow your own instincts I suppose and follow what your baby wants and needs. So I understand maybe it is difficult for health visitors to say well ‘this is how it should be done’, you know, this is the best way because it might not work for your baby. (Mother, first child, 31)

11. Results Advice (cont) One of the major differences in the interviews is that mothers who struggled to breastfeed and changed to formula feeding (or mothers who choose to formula feed from the outset) were much more negative about the advice and support from health professionals, compared to mothers who had breastfed for longer. I think it is a cultural thing, in England they want people to breastfeed as much as they can which is probably a good idea, but they don’t really let you discuss the other options so, it is a bit one sided really ... surely it is more what works for you but some [midwives] have a Gestapo kind of approach to it. (Mother, one child, 33)

12. Results Risk perceptions Ideas of risk and risk perceptions (and the avoidance or minimisation of risks) was a common theme. There was a general attitude of ‘better safe than sorry’, particularly if mothers felt confused or unsure about what the right course of action was. I knew maybe I could have a glass of wine here and there but I just decided not to have any or, you know, maybe you are allowed to have meat rare if you prefer but I decided not to. (Mother, first child, 36) ... if there is any risk then what’s the point and you know, I can do without prawns for nine months, it’s no problem, so I just didn’t, I didn’t feel comfortable eating it if there was any risk. (Mother, first child, age 34)

13. Results Risk perceptions (cont) Risk was commonly cited in relation to breastfeeding, both reasons to breastfeed but also reasons no to. The language of risk was turned on its head and used as a reason to abandon breastfeeding, or not attempt it at all. This kind of stance was usually accompanied with a disclaimer where mothers state that they knew the benefits of breastfeeding (and the risks of not doing so). When you say this to midwives that you are exhausted and you are trying and nothing is happening well, they tell you that you have to try harder, they don’t say ‘OK, that’s enough, you know, you have done your best and to stop’. You will get post-natal depression if you carry on, because you can, you know. (Mother, first child, 34)

14. Results Risk perceptions (cont) Some comments around risk were also linked to notions of lay epidemiology. Babies were often characterised as weak and, particularly in relation to food, in need of special care. Mothers often mentioned potential risks to future health and to future eating habits. I obviously don’t give him more than two or three strong things because his digestive system has to get used to new things and new flavours ... I’m not sure, the taste is more simple, bland, because it is for younger babies and not so strong as the other ones and possibly easier on the digestive system. (Mother, first child, age 32)

15. Results Identity work The morality attached to breastfeeding (and natural birth) are pervasive enough that mothers felt that their status as ‘good’ mothers was threatened. Telling a new mum, well, breastfeed obviously is the best way but formula, if you have any problem, formula is OK, and, you know, formula nowadays, they have everything that your child needs, obviously your own milk will give him extra but just to say, it is OK and just to make the transition easy ... with other mums I have been talking is traumatic because everything is considered wrong for your baby. (Mother, first child, age 32)

16. Results Identity work (cont) It would seem that it isn’t just breastfeeding which has become moralised but also when to wean. Mothers felt the need to justify their decisions if they had weaned before the recommended six months. I talked to a health visitor and just to check it was OK to start weaning so soon because obviously he was very hungry and they said yes, you know, you can start weaning after 19 weeks if your baby’s weight is big enough and he is obviously hungry and the milk is not enough any more, so yeah, I would check with her. (Mother, two children, age 27)

17. Results Identity work (cont) Mothers felt, in some cases, quite hostile towards midwives and health visitors with regards to the perceived support of breastfeeding mothers. Actually, the NHS here is very pro-breastfeeding so you are bombarded with information about breastfeeding and you should breastfeed and it is a bit too much pressure really on new mums to have to go and breastfeed. I think they are, I wouldn’t say wrong, but you know, no one encouraged you to say well, you know, if you have any problems don’t worry and just bottle feed, they pushed you to breastfeed no matter what. (Mother, two children, age 26)

18. Results Healthy eating The concepts of ‘natural’ and ‘homemade’ were frequently mentioned in relation to providing babies with a healthy diet. These concepts were contrasted against ‘processed’ and ‘junk’ food which mothers felt should be avoided for as long as possible. This was also tied up with notions of class and being a good mother. If it has anything other than natural ingredients in it, I won’t give it to her at this stage ... because I can’t see the point of giving her sugar if she doesn’t need it ... she needs vitamins, she needs iron and things like that, she doesn’t need sugar. (Mother, first child, age 40) In [town] I see loads of people, you know the sort, queuing up with their children at McDonalds and I look at it and say there is no way I am taking her to McDonalds ... (Mother, first child, age 34)

21. Mothers felt enormous societal pressures to be perceived to be ‘good’ mothers.Mothers who did not, as they perceived it, conform to society norms with regards to infant feeding or parenting, felt the need to justify their decisions, and to underline their status as ‘good’ mothers. The language of risk was commonly used, both to underline their status as ‘good’ mothers and to justify the decisions. Health risks, particularly related to healthy eating, was something mothers worried about and tried to minimise. Concepts of ‘natural’ and ‘homemade’, as opposed to ‘junk’ food were often talked about. Mothers felt a huge pressure to ‘get it right’ as there seemed to be so much riding on their decisions (future health, intelligence etc) and so much which could go wrong (fussy eating, childhood obesity etc) Many mothers were very conscious of risks and adopted a ‘better safe than sorry’ approach. Limitations: this was a pilot study so a small, purposive sample, but a larger study is planned to look more closely at how parents (not just mothers) use advice, both in real life but also virtually through online groups, such as Mumsnet.