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İlkay Güngör Satılmış,¹ Büşra Yılmaz¹ and Zehra Acar¹

¹Department of Women’s Health and Gynecological Nursing, Florence Nightingale Faculty of Nursing, Istanbul University – Cerrahpasa, Istanbul, Turkey (Correspondence to: B. Yılmaz: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Mothers face social and cultural obstacles to breastfeeding in public.

Aims: This study evaluated the attitudes and practices of Turkish women regarding breastfeeding in public.

Methods: This cross-sectional, descriptive study was carried out in a university hospital among 200 new postnatal mothers and their 200 accompanying female relatives. Data were obtained using a questionnaire and the Infant Feeding Attitude Scale (IIFAS).

Results: Respondents mostly believed that there was nothing wrong with breastfeed in public and almost half of them thought the society would perceive breastfeeding in public negatively. Some 56.5% of the mothers who had previously had children and 37.2% of their relatives had breastfed in public before. The acceptance of breastfeeding in public increased “if the breast is covered” and “if a private space is provided”. The mean total IIFAS score was 61.53 (6.19) in the mothers and 60.65 (6.69) in their relatives. Based on IIFAS, the mothers (92.0%) and their relatives (89.5%) were neutral to breastfeeding, but age, education, employment status, and opinions regarding breastfeeding in public affected the IIFAS scores. IIFAS score was significantly higher in women who had breastfed in public before.

Conclusion: Although the women knew the importance of breastfeeding, they mostly did not breastfeed in public because of the cultural implications and the lack of private breastfeeding areas. Awareness-raising, availability of breastfeeding rooms, and education of supporting relatives can help the increase willingness of mothers to breastfeed even if it is in public.

Keywords: attitudes, public breastfeeding, mothers, relatives, university hospital Turkey

Citation: Satılmış I; Yılmaz B; Acar Z. Attitudes and practices of postnatal mothers and their accompanying relatives to breastfeeding in public at a university hospital in Turkey. East Mediterr Health J. 2022;28(10):733−742. https://doi.org/10.26719/emhj.22.073 Received: 11/08/21; accepted: 29/05/22

Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

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Introduction

The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that babies should be exclusively breastfed for the first 6 months and mothers should continue breastfeeding together with supplementary food until the age of 2 years (1,2). Women are often demotivated from exclusive breastfeeding when they have to breastfeed in public places, including shopping malls, public transport, and workplaces, where women feel anxious about privacy. Breastfeeding in public can cause the woman to be embarrassed and feel ashamed (3). Women who hesitate to breastfeed in public are often unable to practice exclusive breastfeeding, making them to bottle-feed or to cover up their breast while breastfeeding (4). Although the general attitude towards breastfeeding is positive, attitudes and practices towards breastfeeding in public differ between societies. Support for breastfeeding in public is 65.0% in China, 75.0% in Canada, 66.0% in Germany and 72.0% in Africa (5–8). Mulready-Ward and Hackett reported that older women have a more negative attitude towards breastfeeding in public than younger women (9). In an online survey in the United Kingdom of Great Britain and Northern Ireland (UK), acceptance of public breastfeeding increased with educational level and was lower among males and older adults, particularly over 40 years (10).

Breastfeeding in public has become more accepted in developed countries in recent years following media (11), reports that women breastfeeding in public were subjected to verbal and physical violence (12). However, there are not enough studies reflecting attitudes to breastfeeding in public in developing societies (11). In a recent integrative review of women’s experience with breastfeeding in public, most publications were from developed countries such as Australia, the United States of America (USA) and UK. The review recommended further research to increase knowledge of what women want and to support breastfeeding in public (13). The literature states that Muslim societies tend to breastfeed longer and that they generally support breastfeeding (14). However, no specific study has been found on the attitudes and practices towards breastfeeding in public in Turkey.

Patient companions are common in antenatal clinics of Turkish hospitals and in all other units. (15). Mothers, mothers-in-law, sisters, etc. usually support mothers at the hospital and in the first weeks at home after birth. Family members have important supportive roles in breastfeeding and can guide and influence mothers’ breastfeeding practices and motivations (16–18). For these reasons, our study aimed to determine the attitudes and practices of new mothers and their accompanying relatives towards breastfeeding in public.

Methods

Study design

This cross-sectional descriptive study assessed Turkish women’s attitudes and practices around breastfeeding in public.

Study sample

The study population consisted of new mothers and their accompanying female relatives at Istanbul University Hospital in 2019. Inclusion criteria for mothers were: age ≥ 18 years; giving birth to a healthy child; not having a high-risk postpartum complication, or mental or language barriers; having an accompanying female relative during the hospital stay; and agreement to participate in the study. Inclusion criteria for accompanying relatives were: being the main unpaid female companion for the mother during the hospital stay; age ≥ 18 years; not having physical, mental or language barriers for the interview; and agreement to participate in the study. The following sample size calculation formula for known population was used to determine the research sample size (19). While the minimum sample size calculated for mothers was 194, considering possible missing data, 200 new mothers were included in the study. The same number of accompanying female relatives was included, with 1 for each mother.

n=[918×0.80×0.20 ×(1.96)2]/(918–1)×(0.050)2+(1.96)2×0.80 ×0.20=194

n: Number of individuals to be sampled.

N: Population (number of births at the hospital in the previous year) (918).

P: Incidence (acceptance rate for breastfeeding in public in Turkey). According to a global survey including Turkey (20), breastfeeding in public was viewed as wrong by 20.0% of Turkish mothers and the remaining 80.0% viewed it as natural, unavoidable etc. and accepted it completely or partly (0.80).

Q: 1–P (0.20).

d: margin of error (0.050).

Z: z score for 95% significance level (1.96).

Measurement instruments

A questionnaire was prepared by the researchers in accordance with the literature, which included questions about demographic characteristics, obstetric history, breastfeeding history, and attitudes and practices around breastfeeding in public (8, 10).

Iowa Infant Feeding Attitude Scale (IIFAS)

The scale developed by De La Mora and Russell in 1999 evaluates women’s attitudes towards breastfeeding and estimates the duration of breastfeeding, as well as the choice of feeding methods (21). The scale is a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree) and consists of 17 items. Nine items show a positive attitude towards breastfeeding, while 8 show a positive attitude towards formula and bottle feeding. The formula feeding items are scored in reverse (1 = 5, 2 = 4, 4 = 2 and 5 = 1). The total attitude score ranges from 17 (indicating a positive attitude towards bottle feeding) to 85 points (indicating a positive attitude towards breastfeeding). Total IIFAS scores can be further categorized into groups: 70–85 shows a tendency towards breastfeeding; 49–69 a neutral stance; and 17–48 a tendency towards formula and bottle feeding (22–24). Reliability and validity tests of IIFAS were conducted by De La Mora and Russel in three studies in Iowa, and they reported Cronbach’s alpha coefficient of 0.86 in the first 2 studies and 0.68 in the third study (21). The scale was adapted adapted to Turkish language in 2016 by Ekşioğlu et al. and the Cronbach alpha coefficient was 0.71, and is a reliable and valid instrument to determine whether mothers are at risk of early breastfeeding cessation (25). In this study, the Cronbach alpha coefficient was 0.63 for the Turkish version of IIFAS.

Data collection

New mothers at the hospital usually remain in hospital for 24–48 hours after childbirth. The data were collected by the researchers through face-to-face interviews with the mothers and their accompanying female relatives in the mothers’ rooms before discharge.

Ethical considerations

Approval was obtained from the Clinical Research Ethics Committee of the related Istanbul University Faculty of Medicine (No: 79174, Date: 16 March 2018). Informed consent was obtained from the participants who met the inclusion criteria and information about anonymity and confidentiality were explained to the participants.

Data analysis

Percentage, mean, median, standard deviation, and minimum and maximum values were used in descriptive statistics. The Kolmogorov–Smirnov test was used to test for normality of the main dependent IIFAS score. The IIFAS scores deviated significantly from normality (Kolmogorov’s D statistic, D(400) = 0.59, P = 0.002). Although skewness (–0.470) and kurtosis (0.523) values were acceptable for normal distribution, a histogram showed a tendency to left-skewed distribution, and detrended normal graphs showed that the variable was not normally distributed. Therefore, nonparametric tests were used for the comparisons. The Mann–Whitney U test was performed for the analysis of the difference between the median of the non-normally distributed data for 2 groups. Kruskal–Wallis variance analysis was performed for > 2 groups. The Cronbach alpha coefficient was calculated to analyse the reliability of the scale. The level of significance was P < 0.05.

Results

Sociodemographic characteristics of the mothers and their female relatives are shown in Table 1. Characteristics of pregnancy and birth are shown in Table 2.

Most of the mothers and relatives (both 71.0%) said that breastfeeding in public would draw attention (Table 3). When asked how they thought the public would respond to breastfeeding in public, 50.0% of mothers and 48.5% of relatives said they anticipated negative responses. Most mothers (72.0%) and relatives (63.5%) thought a woman has the right to breastfeed in public, but only 62.0% and 56.5%, respectively, said that breastfeeding in public would be acceptable. However, if a private room were provided, breastfeeding in public would be acceptable to 75.0% of mothers and 83.0% of relatives. Most of the mothers (74.5%) and relatives (69.0%) said they had seen a woman breastfeeding in public and were comfortable with that (67.7% and 57.9%, respectively). It was determined that 56.5% of the mothers with previous children and 37.2% of relatives had breastfed in public. Some 32.9% of first-time mothers experienced a form of breastfeeding in public (in hospital in the presence of others/visitors, etc.) during their postpartum hospital stay. Although 40.8% of the mothers who had breastfed in public thought they were drawing attention, only 37.6% felt comfortable. For relatives, 46.2% who had breastfed in public felt comfortable, and 32.8% felt they were drawing attention. Some 81.5% of mothers and 77.0% of relatives said they would breastfeed in the breastfeeding room located in shopping malls.

The total IIFAS scores were similar in mothers [mean 61.53 (6.19); median 62] and their relatives [mean 60.65 (6.69); median 61) (P > 0.05) (Table 4). It showed that 3.0% of mothers and 4.0% of relatives showed a tendency towards breastfeeding, while 5.0% of mothers and 6.5% of relatives tended towards formula bottle feeding. Most mothers (92.0%) and relatives (89.5%) were undecided. Variables about the birth in postnatal mothers including type of birth, planned pregnancy, perception of birth experience and sex of baby were not found to be related with the IIFAS score (P > 0.05). Among mothers, mean IIFAS score was significantly higher among those who had a university degree (P < 0.000), who were employed (P = 0.003) and had a good income (P = 0.016). Relatives aged 25–34 years (P = 0.008) and who had a university degree (P < 0.000) had higher IIFAS scores, while the mean IIFAS score was lower in relatives who were from Eastern Anatolia (P = 0.046) and had ≥ 2 children (P = 0.008). Mothers and relatives who thought it was their right to breastfeed in public (P = 0.001) and found the practice acceptable (P < 0.000) had higher total IIFAS scores than women who were undecided or had negative perceptions regarding the issue.

Discussion

In the current study, new mothers and their accompanying relatives mostly believed that it was their right to breastfeed in public; however, their breastfeeding experiences in public were limited because of cultural concerns and lack of suitable environments. Positive infant feeding attitudes were related to sociodemographic characteristics and breastfeeding experiences in public.

The attitudes and practices of female relatives about breastfeeding influence mothers’ decisions to initiate and continue breastfeeding (16). In Turkish culture, maternal grandmothers/mothers-in-law are prominent during breastfeeding as well as in raising children, and share many experiences with mothers. One study showed that mothers, regardless of their age and education level, were affected by the experiences of the older generation and felt pressure during breastfeeding (18). It is considered important to examine the opinions of women who are family members and have the potential to influence and support maternal decisions about breastfeeding in public.

One of the factors that determine the continuation of breastfeeding is the necessity of breastfeeding in public spaces. A study in Ghana reported that while 77.0% of women thought that mothers have the right to breastfeed in public, only 62.7% stated that it is acceptable (8). In a study in China, 65.0% of the participants stated that breastfeeding in public is acceptable (5). In a global survey conducted by a leading manufacturer of breastfeeding accessories that included 13 000 mothers from Brazil, China, France, Germany, Hungary, Mexico, Turkey, UK and USA in 2014, breastfeeding in public was viewed as wrong by 20.0% of Turkish mothers, which was the highest rate among the countries (20). In this study, although 72.0% of mothers and 63.5% of relatives believed in the right to breastfeed in public, only 62.0% and 56.5%, respectively, found it acceptable. The closeness of the acceptance rates in the different studies indicates that many women in different cultures have similar cultural, religious and environmental concerns that affect their attitudes towards breastfeeding in public.

Seeing a woman breastfeed in public often raises complex and negative emotions. A recent review of women’s experiences with breastfeeding in public across diverse international contexts revealed the challenges to include drawing attention, sexualization of breasts, awareness of others’ discomfort, and efforts not to be seen, while women’s perceptions of what enhanced their experience were confidence and a supportive audience (13). In another recent online survey on women in Australia, Ireland and Sweden, challenges to breastfeeding in public included unwanted attention, no comfortable place to sit, unsuitable environment, awkward audience, and not wearing appropriate clothing, while supportive network, quiet private environment, comfortable seating, understanding and acceptance of others, and seeing other mothers breastfeeding were helpful (26). A study conducted in the USA found that 33.2% of participants felt uncomfortable when they saw a woman breastfeeding in public (5). In another study in China, 47.0% said that seeing a woman breastfeeding in public was embarrassing (5). In a study conducted in the UK, participants did not know where to look when they saw a breastfeeding mother and they felt shame (10). Attitudes towards breastfeeding in public are mostly related to perceived cultural norms (27). In a meta-synthesis, grandmothers thought that breastfeeding in public causes embarrassment or disapproval of mothers because the breast represents sexuality (17). In this study, feeling anxious (mothers 13.4%, relatives 15.9%), uncomfortable (mothers 10.0%, relatives 18.1%) and ashamed (mothers 8.9%, relatives 8.1%) were reported. However, these negative attitudes may be evaluated as low because mothers use breastfeeding covers and prefer breastfeeding cabins/rooms when in public.

Women who breastfeed in public can be accused of having bad ethical values and of being bad parents (28). It is expected that women would take necessary precautions due to reactions from other people when breastfeeding in public places, to minimize the problems that may occur, and keep themselves safe (12). Mothers are expected to work, do the shopping, and take their babies to hospital. In such situations, mothers prefer to prepare breastmilk beforehand or use formulae, use unsuitable environments such as bathrooms or toilets, and/or cover their breast while breastfeeding in public places to avoid embarrassment (27,28). In Ghana, 81.0% of participants said that women should cover their breast and 70.3% that mothers should breastfeed in specially designated places and rooms (8). A study in Romania showed that mothers need a secluded and safe environment when breastfeeding outside their homes, and not being able to find such a place can create tension for mothers who want to breastfeed in public (29). In this study, the acceptability of breastfeeding in public increased when the breast was covered (mothers 69.5%, relatives 70.5%) and when a private area was provided (mothers 75.0%, relatives 83.0%). Breastfeeding is restricted to the home environment or expected to be performed in environments such as public toilets due to lack of suitable conditions. It should be a mother’s choice whether to use a cover or private room, and depends on their own values and perception of privacy.

Beyond covering the breast, mothers’ attitudes before and during breastfeeding are important for the acceptability of breastfeeding in public (10). A study determined that mothers felt pried upon while breastfeeding and that this made them feel anxious. Many mothers feel comfortable when breastfeeding in the presence of other women but uncomfortable when breastfeeding next to their fathers, friends of their husband, or strangers (30). Hauck et al reported that, women who had to breastfeed in front of someone they felt uncomfortable, most often tried not to be seen, moved to a private place, turned away and just got on with breastfeeding (13). Similarly, in this study, more mothers felt uncomfortable breastfeeding in the presence of a man. This can be explained by the fact that the breast is associated with sexuality, and the mothers’ perception of privacy.

Mothers’ infant feeding attitudes may affect their views on breastfeeding in public (27). A study conducted in Korea found a positive relationship between breastfeeding in public and breastfeeding continuation (31). Another study reported that people with knowledge about breastfeeding or who have seen people breastfeed in public had greater positive attitudes towards breastfeeding in public (5). Similarly, our study found that mothers and relatives with positive attitudes towards breastfeeding in public and mothers who breasfed in public were more positive. In addition, higher IIFAS scores in mothers who had a university degree, who were employed or had a good income demonstrate the importance of social status of women for increased awareness about breastfeeding. In the same way, relatives aged 25–34 years with higher IIFAS scores or who had a university degree were the most effective for supporting mothers, with their positive attitudes about breastfeeding. Health professionals must be aware that older relatives from less developed regions with ≥ 2 children may need more education to increase their awareness and positive attitudes while supporting mothers. Most mothers and relatives were neutral/undecided towards breastfeeding and health professionals can help them become more positive through education.

Positive role models and social values that support breastfeeding in a normal and desired manner contribute positively to breastfeeding attitudes. Within the scope of the 2016 Breastfeeding Week, the WHO and UNICEF created many brochures with the slogan “Support mums to breastfeed anytime, anywhere”. An online pilot study showed that brief exposure to 4 different images of public breastfeeding resulted in a marginal increase in positive attitudes toward public breastfeeding (32). Similarly, every country should use this power of the media to create social awareness in line with its own social and cultural values.

This study had some limitations. The results from this hospital-based sample in Istanbul cannot be generalized to the country. Questioning the views of new mothers may have caused them to display a more positive attitude towards breastfeeding in public. In addition, the accompanying relatives of the mothers were mostly their mothers and were within a certain age category.

Conclusion

This study found that women generally believe it is their right to breastfeed in public. There were negative attitudes towards breastfeeding in public but it was acceptable if the breast was covered or when a special environment was provided. Positive infant feeding attitudes were related to sociodemographic characteristics and breastfeeding experiences in public. Besides informing about the health benefits of breastfeeding, addressing common attitudes towards breastfeeding in public can help promote breastfeeding. Media support can help raise awareness and eliminate negative perceptions. Availability of breastfeeding rooms will also contribute to sustaining breastfeeding. Mothers’ own values and perceptions of privacy should be evaluated and mothers should be encouraged to breastfeed when and where they and their babies need it. Health professionals should be aware of the importance of relatives in breastfeeding support, and should provide opportunities for the accompanying support person to participate in breastfeeding education with mothers.

Funding: None

Competing interests: None declared.

Attitudes et pratiques des mères en période postnatale et de leurs accompagnatrices de l'entourage proche vis-à-vis de l'allaitement en public dans un hôpital universitaire en Turquie

Résumé

Contexte : Les mères font face à des obstacles sociaux et culturels concernant l'allaitement en public.

Objectifs : La présente étude a évalué les attitudes et les pratiques des femmes turques en matière d'allaitement en public.

Méthodes : Cette étude transversale et descriptive a été menée dans un hôpital universitaire auprès de 200 nouvelles mères en période postnatale et de leurs 200 accompagnatrices de l'entourage proche. Les données ont été obtenues au moyen d'un questionnaire et de l'échelle d'attitude à l'égard de l'alimentation des nourrissons (IIFAS).

Résultats : La plupart des personnes interrogées pensaient qu'il n'y avait rien de mal à allaiter en public et près de la moitié d'entre elles étaient d'avis que la société perçoit négativement l'allaitement en public. Près de 56,5 % des mères qui avaient déjà eu des enfants et 37,2 % de leurs proches avaient déjà allaité en public. L'acceptation de l'allaitement en public était renforcée « si le sein est couvert » et « si un espace privé est prévu ». Le score total moyen de l'échelle d'attitude à l'égard de l'alimentation des nourrissons était de 61,53 (6,19) chez les mères et de 60,65 (6,69) chez leurs proches. Selon cette échelle, les mères (92,0 %) et leurs proches (89,5 %) étaient neutres vis-à-vis de l'allaitement, mais l'âge, le niveau d'éducation, le statut professionnel et les opinions concernant l'allaitement en public affectaient les scores IIFAS. Ces derniers étaient significativement plus élevés chez les femmes qui avaient déjà allaité en public.

Conclusion : Même si les femmes connaissaient l'importance de l'allaitement, elles n'allaitaient généralement pas en public en raison des implications culturelles et du manque d'espaces privés pour l'allaitement. La sensibilisation, la disponibilité de salles d'allaitement et l'éducation des proches qui soutiennent les mères peuvent contribuer à accroître la volonté des mères d'allaiter, même dans un lieu public.

اتجاهات الأمهات بعد الولادة وقريباتهن المرافقات من مباشرة الرضاعة الطبيعية في الأماكن العامة وممارساتهن في هذا الصدد: دراسة في أحد المستشفيات الجامعية في تركيا

إلكاي جونجور ساتيلمز، بشرا يلمز، زهرة أكار

الخلاصة

الخلفية: تواجه الأمهات عقبات اجتماعية وثقافية بشأن مباشرة الرضاعة الطبيعية في الأماكن العامة.

الأهداف: هدفت هذه الدراسة الى تقييم إتجاهات النساء التركيات إزاء مباشرة الرضاعة الطبيعية في الأماكن العامة وممارساتهن في هذا الشأن

طرق البحث: أُجريت هذه الدراسة الوصفية المقطعية في مستشفى جامعي، وضمت 200 من الأمهات حديثات الولادة و200 من قريباتهن المرافقات. وقد جُمِعت البيانات باستخدام استبيان ومقياس توجُّهات تغذية الرُّضَّع.

النتائج: غالبًا ما رأت المشارِكات في البحث أنه لا ضير ولا خطأ في مباشرة الرضاعة الطبيعية في الأماكن العامة، ولكن رأى نصفُهن تقريبًا أن المجتمع سينظر إلى مباشرة الرضاعة الطبيعية في الأماكن العامة نظرةً سلبية. وتبيَّن أن نحو 56.5% من الأمهات اللاتي سبق لهن الإنجاب و37.2% من قريباتهن قد أرضعن أطفالهن في الأماكن العامة من قبل. وزاد تقبُّل مباشرة الرضاعة الطبيعية في الأماكن العامة في حالة «تغطية الثدي» و«توفير مكان خاص للأمر». وكان متوسط إجمالي النتيجة على مقياس توجُّهات تغذية الرُّضَّع 61.53 (6.19) لدى الأمهات و60.65 (6.69) لدى قريباتهن. وحسب مقياس توجُّهات تغذية الرُّضَّع، فإن 92.0% من الأمهات و89.5% من قريباتهن لديهن موقف محايد من مباشرة الرضاعة الطبيعية، ولكن عوامل العمر والتعليم والوضع الوظيفي والآراء المتعلقة بمباشرة الرضاعة الطبيعية في الأماكن العامة أثَّرت جميعًا على النتائج في مقياس توجُّهات تغذية الرُّضَّع. كانت النتائج على مقياس توجُّهات تغذية الرُّضَّع أعلى كثيرًا لدى النساء اللاتي سبق لهن مباشرة الرضاعة الطبيعية في الأماكن العامة.

الاستنتاجات: إن النساء يعرفن أهمية الرضاعة الطبيعية، ومع ذلك فإنهن في الغالب لا يُرضعن أطفالهن في الأماكن العامة بسبب العوامل الثقافية، وغياب مناطق خاصة لمباشرة الرضاعة الطبيعية. لذا يمكن لزيادة الوعي، وتوفُّر غُرَف لمباشرة الرضاعة الطبيعية، وتثقيف الأقارب الداعمين، أن يساعد في زيادة استعداد الأمهات لمباشرة الرضاعة الطبيعية، وإن كان ذلك في الأماكن العامة.

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