Understanding early cessation of exclusive breastfeeding: a mixed method study

This thesis investigates the prevalence of early cessation of exclusive breastfeeding in Australia, with early cessation defined as the point when an infant fed exclusively on breast milk is first fed infant formula or other foods/fluids before the first 6 months of age. The thesis identifies key factors associated with low rates of exclusive breastfeeding, and explores both how mothers experience breastfeeding and the cessation of exclusive breastfeeding.

The research used a mixed methods approach that combined secondary analysis of questionnaire data with qualitative focus group (FG) data. A nationally-representative sample of 22,202 breastfeeding mothers and infant pairs was derived from the 2010 Australian National Infant Feeding Cross-Sectional Survey. This sample was analysed using survival analysis (stratified Cox proportional hazard model) to identify prevalence of exclusive breastfeeding and factors associated with cessation of exclusive breastfeeding within the first 6 months. Data from 22 FGs, involving 108 Tasmanian mother-child pairs was used to explore mothers’ experiences of breastfeeding and cessation of exclusive breastfeeding. Pierre Bourdieu’s theory of practice provided a theoretically derived framework for the qualitative analysis.

This research revealed that few infants aged less than 6 months, are exclusively breastfed. Half of the national questionnaire sample had ceased exclusive breastfeeding before the first two months. Multiple factors were associated with interrupting exclusivity, with the mothers’ partners’ preference for bottle-feeding, or having no preference most strongly associated with cessation. The final Cox regression adjusted multivariate model showed that mothers with education levels below bachelor degree, who smoked cigarettes, were obese and or overweight, diagnosed with perinatal depression, had fed their infants expressed milk and used a dummy regularly, and whose infants had not received skin to skin at birth, were independently associated with an increased hazard ratio of interrupting exclusive breastfeeding.

Analysis of FG data found that the preference, to breastfeed appears to be integral to the maternal habitus in Australia. Mothers in the FG study understood breastfeeding as feeding from the breast, and valued this form of feeding above all other milks and methods because it is viewed as natural. However, the concept of “exclusive breastfeeding” had little relevance for them. Despite the value given to breastfeeding, many women struggle to convert their embodied physical capital (breasts, milk, nipples) to feed their children. Mothers described deploying non-maternal capital such as fathers and dummies as “allofeeding” methods to support breastfeeding. Despite this support, early cessation of exclusive breastfeeding through the use of infant formula is common. A disjuncture thus occurs between practice, what mothers do (use formula) and the maternal habitus, (to breastfeed). As a result, many mothers are unable to “make sense” of their use of formula resulting in powerful feelings of personal and social failure and breastfeeding grief.

This research contributes to public health and sociological understandings of early cessation of exclusive breastfeeding. It identifies factors that are associated with cessation of exclusive breastfeeding, offers insights into how women perceive and experience exclusive breastfeeding and describes what it is like for breastfeeding mothers to cease exclusive breastfeeding through the use of infant formula. Given that interactions between multiple factors are associated with early cessation of exclusive breastfeeding the development of strategies to support exclusive breastfeeding is likely to be challenging. Greater recognition of the value of the allofeeding support provided by fathers (or other partners) and engaging and supporting more fathers to be collaborative breastfeeding partners may be an effective strategy. Reframing breastfeeding as a cooperative practice may also help alleviate that guilt and shame many women experience as a result of disjuncture.